In the middle of the Covid pandemic, when the NHS and its staff are going flat out to cope, NHS England (NHSE) is stealthily transforming the NHS again. What is portrayed as an innocuous move to ‘integrate’ care and reduce bureaucracy will, in effect, move decision-making even further from local communities and increase the presence and influence of the private sector in the NHS.
At the moment, the main tools for this transformation are Integrated Care Systems (ICSs), supported by plans for new legislative powers. Although ICSs are already in place in some parts of England, a new document from NHSE provides the clearest glimpse so far of what ICSs could mean.
The proposals, recently echoed in a government White Paper, are of huge concern. Although seen by the media as suggesting the role of the private sector will be reduced, the proposed legislation, if passed, will enact the current government’s wish to further fragment, destabilise and privatise our NHS.
Regulations brought in by the Health and Social Care Act (HSCA) of 2012 enforced a new competitive ‘market’ within the NHS. The Act also introduced Clinical Commissioning Groups (CCGs) that were required to put clinical and other services out to competitive tender and so allowed increased private company involvement in the NHS.
Since then, while still retaining the market system, NHSE has declared that competition is to be replaced by the “integration” of NHS, local authority and other service providers. NHSE’s ‘integration’ has involved fragmenting the NHS into 44 areas (originally called ‘Sustainability and Transformation Plans’) destined to eventually morph into 42 Integrated Care Systems. The NHS Long Term Plan requires every NHS organisation and their local ‘partners’ to become part of an ICS by April of this year.
What are ICSs?
According to NHSE, ICSs are bodies in which
“NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.”
The ‘others’ they refer to include private companies. An ICS will have a ‘single pot’ budget and its partners will collectively decide how to delegate that budget to loosely defined local “places” within the ICS.
The powers of ICSs are currently under review [LINK TO PAPER ON ICS LEGISLATION PROPOSALS]. NHSE argues that existing law, such as the HSCA (2012), does not provide a sufficiently firm foundation for the work of ICSs, so they propose scrapping Section 75 of the Act, which, for example, requires commissioners to put any contract worth over £.615,278 out to tender. They have also sought views on two options for enshrining ICSs in legislation.
Both options provide an ICS Board and a single ICS Accountable Officer. In one option, there would be a single Clinical Commissioning Group (CCG), along with a new duty for providers, such as NHS Trusts, to comply with the ICS plan. In the second option, NHSE’s preference, CCGs would be ‘repurposed’, whatever that means, and their commissioning functions transferred to the ICS Board. While the veto of individual organisations within the ICS would be removed, the ICS could delegate responsibility for arranging some services to providers “to create much greater scope for provider collaboration”.
What are the main issues for campaigners?
ICSs raise multiple issues but we focus on three main areas: the increased potential they offer for private companies to profiteer from the NHS; the unequal partnership they create with local authorities and the subsequent threat to social care and public health services; and the loss of accountability.
Increased scope for private companies
Removing Section 75 of the HSCA (2012), by itself, won’t reverse the marketisation of the NHS. Worse still, it would involve revoking Procurement, Patient Choice and Competition Regulations, so turning the NHS into an unregulated market.
The proposals also recommend that NHS services be removed from the scope of the Public Contracts Regulations 2015, allowing commissioners more discretion when procuring services. It means that ICSs would be able to choose whether to award a contract directly to a provider or go through a more formal procurement process. Such flexibility massively increases opportunities for cronyism, as shown during the Covid pandemic when emergency measures allowed the usual procurement rules to be bypassed. For example, the National Audit Office found that during the early stages of the Covid crisis, companies with ‘connections’ (for instance with government officials, MPs, or senior NHS staff), were ten times more likely to be awarded a contract than those without such links – even if they were entirely unsuitable suppliers.
The possibility that ICSs, operating in a market system, can chose to dispense with formal procurement processes is additionally alarming as NHSE wants to give each ICS a free hand in appointing its governing Board. This means that these Boards could include representatives from private providers – a move that’s described as “a blatant undermining of the ICS as an NHS body”.
The way that ICSs are to be internally managed will also increase privatisation. NHSE has accredited 83 companies to provide support for developing and managing ICSs through what’s known as the Health Systems Support Framework (HSSF). In the words of NHSE,
“The Health Systems Support (HSS) Framework provides a quick and easy route to access support services from innovative third party suppliers at the leading edge of health and care system reform”.
These companies, as you might guess, include McKinsey, Deloitte, Optum, IBM, Ernst and Young, Centene, and other global corporations, along with some UK and European companies, and a handful of NHS Commissioning Support Units.
The HSSF is divided into 10 ‘Lots’ covering services such as patient record systems, transformation and change support, capacity planning support, patient empowerment, and digital tools to support system planning. As NHSE points out,
“The Framework focuses particularly on services that can support the move to integrated models of care based on intelligence-led population health management. This includes new digital and technological advances that help clinicians and managers understand a population’s health and how it can best be managed.” (Our emphasis)
Population health management (PHM) is described by NHSE as “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.”
Briefly, PHM (“the critical building block for integrated care systems”) relies heavily on the mass collection and analysis of data from across multiple care settings, and a shift from care provided by clinicians face-to-face, to much more digitally provided care via remote consultations and algorithms. This inevitably means more private sector involvement due to the capital investment required for digital infrastructure, not to mention increased access to patient data for tech companies.
In addition, PHM shifts the focus of the NHS from delivering universal comprehensive care to individuals towards achieving data targets for the population covered by the ICS. Depending of course on how, and by whom, and with what aim, those data targets are set, what’s “good” for the population may be at odds with the needs of an individual.
The threat to social care and public health services
ICSs are an essential part of a shift towards a ‘place-based approach’ to health and social care, with ‘place’ often seen as coterminous with local authority (LA) boundaries. According to the NHS Confederation, this level of working is the right scale for tackling ‘population health challenges’, such as health inequalities. A ‘place based approach’ is also part of a shift towards PHM, as well as shared responsibility for resources and service changes across all public services within the area.
NHSE proposals suggest that ICSs become the means for more ‘integration’ between the NHS and LAs. However, in its response to NHSE’s proposals, the Local Government Association (the national voice for local government) raises concerns that ICSs won’t be a partnership of equals across the broader health, wellbeing, and social care system. Instead, ICSs will be NHS-led, allowing a power grab that brings LA resources such as capital assets and funding for social care and public health under ICS (and thus NHS) control. There is also a risk that power won’t be devolved to local systems. Rather, central control will remain, with missed opportunities for real collaboration between the NHS and LAs to address the wider determinants of health, such as affordable housing and a safe environment.
Further, KONP among others has highlighted the risks posed by NHS management of social care. Social care is not an adjunct of the NHS, but has a very wide remit that overlaps with wider local authority responsibilities including housing, leisure, planning and education. In addition, social care is means tested while NHS care is (largely) free at the point of use and funded by taxation. If ICSs take on social care, they will have to develop complicated charging mechanisms. This could pave the way to charges for NHS services or, long term, for the introduction of a private insurance-based system (facilitated, incidentally, by the extensive data sets created by PHM). NHSE’s proposals also fail to mention any safeguards to prevent services that are currently free from being redefined as social care and so subject to means testing.
Loss of accountability
In contrast to local authorities, ICSs are not subject to democratic control. NHSE’s proposals will give them the power to create publicly unaccountable joint committees, potentially including representatives from private business, to make legally binding decisions about major resource allocation and service provision. (For KONP’s vision for achieving democratic accountability, see here.)
CCGs, with their responsibility to manage local budgets, will be weakened or, as NHSE would prefer, abolished. In the absence of any plans to make ICSs accountable to local residents or patients, it seems that people over large areas of England will be disenfranchised. Although ICS Boards will supplant existing public bodies, there appears to be no requirement for them to meet in public, publish their Board papers and minutes, be subject to the Freedom of Information Act, or to have any democratic participation from the communities they cover.
What can we do?
KONP calls for a halt to the development of ICSs until there is a full consultation with the public, local authorities and Parliament. It argues that not just Section 75 but the entire Health and Social Care Act (2012) should be repealed and the NHS Reinstatement Bill laid before Parliament. This proposes restoring the NHS as an accountable public service; ending contracting and the purchaser-provider split; and re-establishing public bodies and public accountability to local communities.
We call on Councillors and MPs to be briefed in detail on the issues before legislation is tabled, and to be ready to challenge it.
We call on activists to make these issues a campaign focus, before legislation is tabled.
As and when the Government publishes legislation, we will respond in detail.