Select Committee report on Integrated Care and ACOs

PUBLICATION OF HEALTH AND SOCIAL CARE COMMITTEE REPORT ON INTEGRATED CARE: ORGANISATIONS, PARTNERSHIPS AND SYSTEMS 

The Health and Social Care Committee (HSCC) has published its report on Integrated Care: organisations, partnerships and systems today. Keep Our NHS Public (KONP) contributed written evidence [1], gave oral evidence 27 February (Dr Tony O’Sullivan, retired paediatrician and co-chair of KONP) and followed this up with supplementary evidence. [2]

KONP statement:

While we welcome certain conclusions of the HSCC, the overall message defends NHS England (NHSE) and the Department of Health & Social Care (DHSC) in their policy direction of introducing accountable care organisations that are dangerous in bringing in models of care based on the deskilling of a workforce designed to give cheaper, underfunded care in the community.

We suspect that the report does not convey a single coherent message but reflects the various different positions of committee members, who have reached a compromise to agree a published report.

A key tenet put forward by KONP is that ACOs are illegal under the current legislation and are an unlawful ‘workaround’. The HSCC has accepted this:

The legal barriers and fragmentation that arose out of the Health and Social Care Act 2012 will need to be addressed … ACOs, if introduced, should be NHS bodies and established in primary legislation.

KONP believes that this is a vindication of one of the key bases for the current Judicial Review (JR) heard 23-24 May (ruling by Mr Justice Green expected in the next few weeks) taken against NHSE and Secretary of State Jeremy Hunt. Five individuals (one now deceased, Professor Stephen Hawking) challenged their attempt to introduce ACOs from April 2018 using secondary regulation, originally planned to be laid down in February 2018, and only delayed in the face of a defeat at JR. However, the HSCC gives a green light to further Government attempts to ‘workaround’ primary legislation:

Where barriers are identified and can be removed with secondary legislation, this may represent a less complex way forward.

We reject this concession to Government attempts to totally reconfigure and break up the NHS without the scrutiny that would accompany primary legislation.

We believe that the HSCC, while denying that ACOs facilitate privatisation, has also responded to the public concern over the risk of that privatisation poses through ACOs. It is beyond dispute that the awarding of 10-15 year contracts to manage ACOs with multi-billion pound annual turnover constitutes a risk of privatisation of the NHS of unparalleled scale to date.

Given the risks that would follow any collapse of a private organisation holding such a contract and the public’s preference for the principle of a public ownership model of the NHS, we recommend that ACOs, if introduced, should be NHS bodies and established in primary legislation.

There is also recognition that the timescale of 5 years that Simon Stevens, CEO of NHSE laid down in his Five Year Forward View has been unrealistic within the context of unparalleled underfunding and in our view a total failure of workforce strategy since 2010:

Countries that have made the move to more collaborative, integrated care have done so over 10–15 years and with dedicated upfront investment … A long-term funding settlement and effective workforce strategy are essential not only to alleviate immediate pressures on services, but to facilitate the transition to more integrated models of care.

It is misleading to imply that NHSE and Jeremy Hunt have merely failed to communicate their intentions adequately – a conclusion unmistakeably drawn from the title of the press release: ‘Government and the NHS must improve how they communicate NHS reforms to the public, say MPs.’ There has been no misunderstanding: ACOs and associated policies embodied in the Five Year Forward View and subsequent documents clearly have been in the direction of:

• Delivering healthcare at unprecedentedly lower funding levels (£22bn annual NHS funding below predicted requirement for the NHS to meet needs)
• A break up of the national NHS into 44 or more geographically based non-NHS management bodies called ACOs covering the whole of England
• New cheaper models of health and social care workforce to reduce the level of skills and professional experience and thereby reduce costs
• An opening up of private control, or private-public partnership control of these huge contracts, whilst (unbelievably) denying the risk of privatisation.

KONP and others gave evidence that successful efforts to deliver integrated clinical care have been in existence long before the Five Year Forward View and this Government. The National Audit Office concluded in February 2017 [3] that there is no evidence that organisationally imposed integration delivers better care. We need delivery of coordinated patient care, but formally integrated organisations are not proven to be valuable and require dramatic and damaging widescale reorganisation to achieve.

Dr Tony O’Sullivan, Co-chair of Keep Our NHS Public says:

We welcome that the Select Committee appear to agree with KONP and those who have taken NHSE and Jeremy Hunt to JR, when the HSCC states that ACOs must be subject to primary legislation and should be statutory NHS bodies. We also welcome the conclusions of the Select Committee that ACOs lack evidence that they will deliver better coordinated care; that they are being rushed through and are severely underfunded – massive challenges that are without precedent. We welcome the HSCC’s call for change to be evidence-based and that results of trial areas must be closely evaluated.

We reject the HSCC assertion that competition can be a useful tool, when it has most clearly failed in numerous disasters, not least Carillion and Capita.

We are disappointed that the HSCC paints the abject failures of the Five Year Forward View and NHSE policy as mere misunderstandings. We call for the following further conclusions to be drawn

• privatisation of the NHS in all its forms must be stopped
• safe levels of funding must be restored immediately and must fund a safe and effective workforce strategy
• models of care must be based on clinical evidence and patient outcomes, not on financial restraint imperatives
• the NHS must be restored to a fully public provision, fully funded publicly with restoration of the direct duty of the Secretary of State to provide universal and comprehensive health care to the population

 These requirements to restore the NHS are encompassed in the 10-minute rule Bill to be presented by Eleanor Smith, MP for Wolverhampton South West on 11 July. [NHS Bill back in Parliament]

FURTHER INFORMATION:

The report is available here and on the Committee’s website since 11 June.

Publications / Reports / Reference Material: Committee news and reports, Bills, Library research material and much more can be found via Parliament.  All proceedings can be viewed live and on-demand at www.parliamentlive.tv

Tony O’Sullivan

1: Resource library – Accountable care

2: KONP follow up submission

3: National Audit Office, February 2017

4: NHS Bill Reinstatement Campaign