Brenda Allan, Alan Morton, Hornsey & Wood Green CLP; North Central London NHS Watch, and Rod Wells, Haringey Keep Our NHS Public (KONP).  020122

None of the longstanding and growing problems facing the NHS and  Social Care, i.e. underfunding, workforce shortages and retention problems, the pre pandemic backlog, long waiting lists, the impact of the pandemic, low morale, privatisation inefficiencies and wastage, health inequalities, and more, are addressed by this Bill. Its timing, in the middle of a pandemic, will cause further disruption to staff and patient care, when all efforts should be geared to tackling the real issues and the pandemic. 

1.Representation and accountability

1.1 Primary Care and Local Authorities, with the latter’s responsibility for Social Care and Public Health,  should  have parity of representation and voting rights at all levels and committees of the ICS structures, including the ICB and Partnership Board.  At the very least, there should be significantly increased voting representation, not just  the one for primary care, one for Local Authorities and none for Public Health, as in the current Bill.  (Clauses 12-25)

1.2. The primary care representatives should be drawn from practices on PMS or GMS contracts, not corporate Alternative Provider of Medical Services (APMS) ones.

1.3. Robust patient participation and representation is key to ensuring health planning actually meets the needs of patients and carers. This should go beyond information sharing and consultation exercises, to also include direct collaboration, co-production and representation on the ICB and other committees, with membership drawn from patient participation groups and carers groups. (Clause 19 covers requirements for ICBs to involve the public and patients in the commissioning process, which appears to be broadly similar to CCG duties).  However, the ICSs cover more services and has greater powers, and the current representation arrangements on CCGs is regarded by many groups as totally inadequate. 

1.4. Measures need to be in place to ensure that ICSs are fully accountable to local councils, the public, and patients. Meetings must be held in public, and papers/minutes etc made public.

1.5. ICSs should be subject to FoIs. Private providers are not subject to FoIs because of their commercial interests, so if they are permitted board or committee membership, ICSs will not be subject to FoIs,.

2.Secretary of state powers

The increase in the Secretary of State’s powers requires additional safeguards to ensure the SoS’s interventions in local configurations are made for the good of patients and services, and take into account, local public, patient and professional views. 

3. NHS as default provider

3.1.NHS organisations should be enshrined in the Bill as the default provider for all NHS contracts, with competitive tendering reserved solely for when an NHS provider cannot provide an appropriate service.  As the Bill stands, and with the provisions of the Provider Selection Regime (PSR), contracts can be awarded without proper scrutiny or transparency, in a deregulated market, and the NHS would not be protected from unnecessary private sector involvement and further fragmentation of services. (Clauses 67-73).

3.2.ICSs should use the PSR to continue, or directly select, existing NHS providers. As private contracts fall due for renewal, the default position should be that they are awarded to NHS providers; if this not possible, there should be a transparent tendering process,  using the Social Value Act to try and deliver wider, and where possible, local  socio-economic benefit. This would help avoid the further service fragmentation, non- delivery and waste of taxpayer’s money witnessed during the pandemic. 

4. Involvement of private providers

4.1. Private providers, including GPs from practices on APMS contracts, should be excluded from membership on decision-making/resource allocation ICS boards and committees. 

4.2. The remaining elements of the expensive and wasteful private market tendering, and direct, unscrutinised awarding of contracts to private companies, should be ended. (Clauses 67-73)

5.Capped budgets and funding

The Bill states that ICBs and their partner NHS and Foundation trusts must operate with a view to ensuring that expenditure does not exceed the limits set by NHSE for that financial year.  The ability to run deficits will apparently be reversed and the existing deficits of many trusts and CCGs will weigh heavily on the new capped budgets.  (Clauses 21-24l). This will exacerbate the existing long waiting times, erosion of clinical standards and contribute to increases in mortality and morbidity. (The UK still fails to meet the standards set out in the WHO guidance, 2020 for countries deemed ‘resource restricted’ for the clinical assessments required for patients with suspected COVID.) (1)

 5.1. The capped budgets provision should be withdrawn, especially now when the NHS is struggling with years of underfunding and the impact of the pandemic. 

6. Funding

Crucially, there is an urgent need for greatly increased funding to meet the staff, beds and equipment shortages that existed before the pandemic, resulting in year-round ‘winter pressures’, and long waiting lists, all exacerbated by Covid.  Additionally, annual funding increases of 4% or more must be restored to allow for staff wage increases and recognition that the rate of NHS cost inflation, exceeds the overall national rate, because of complex care and medication needs. 

7.Workforce, training and professional regulation 

7.1. There should be biannual, published assessments of the workforce required to deliver safe, high-quality care. This should take into account the current shortages (over 10% or 100,000 staff in the NHS and 100,000 in Social Care), population increases, the prevalence of health conditions and the impact of technological advances, and must be backed by the necessary funding for a robust recruitment, retention and training drive. The Bill suggests only five yearly reviews. (Clause 33) 

7.2. Staff should be maintained on NHS contracts and terms and conditions.

7.3. There is no merit in the proposals on professional (de)regulation and the powers to deregulate professional regulatory bodies. They should be withdrawn;  their inclusion risks deregulating professions, and endangering skilled, safe patient care.  (Clause 123)

7.4. The abolition of Local Education and Training Boards, with responsibility passed to HEE, risks undermining local initiatives for training and recruitment, and it is crucial that these activities are supported and sustained. (Clause 77)

7.5. Safe staffing levels need to be set for H&C services, and any legislative reform should be used to ensure that these levels are adhered to. This is essential for patient safety, and to ensure confidence and productivity of staff. 

8. Discharge to Assess and Social care

8.1. The reductions in hospital beds (11% between 2010-2020) (1) and the UK’s low rate of beds per head of population, compared with the OECD average, (2)  has led to pressure on discharges. Early discharges with patients having to recover at home whilst still poorly, places an extra strain on primary and social care, and on individuals and families with fewer resources, and/or greater needs.  

8.2. Transition from hospital to home results in 19% adverse incidents for patients, including avoidable symptoms, additional A&E visits, hospital readmissions and death. (2) Yet early discharge with assessments taking place at home after discharge is enshrined in Discharge to Assess and included in the Bill, (Clause 78), with no acknowledgement of the parlous state of primary and social care.  

8.3. Discharge to Assess should be delayed until primary care and social care have adequate capacity.

8.4. The reduction in hospital beds needs to be reversed and capacity increased to the OECD average at least – the BMA estimated there needed to be a minimum of 3000 extra beds to deal with rising demand. (3)

8.5.Social care needs an urgent, massive investment, and reform of the delivery model.    

9. Public health 

9.1. There needs to be increased investment in,  and acknowledgement of, the crucial role in health outcomes, played by social care, public health, other local authority services, and primary care.

9.2 Michael Marmot recommends Public Health should receive 0.5% of GDP; it should be an influential driver of NHS strategy and planning, with a major remit nationally and regionally.

10.Primary care 

10.1. Primary care is in crisis, and Investment is urgently needed. It  provides 90% of patient contacts, yet receives only 10 % of NHS funding, below the OECD average of 14%.  This despite a year’s worth of GP care per patient, costing less than two trips to A&E.  Local Medical Committees reported in August that GP practices could close on a temporary or permanent basis this winter, or reduce services, because of workload and staffing pressures. One LMC predicted a third of its practices will soon be on highest alert because of workload pressures. (4)  There are 1803 fewer GPs now than in 2015.

10.2. Investment in primary care is one of the four features highlighted as crucial in top performing health care systems, to ensure high value services are equitably available; the UK now comes 9/11 for health care outcomes in the Commonwealth Fund ranking. (5)  

10.3. Primary Care urgently needs to receive a larger percentage of NHS expenditure, of at least the 14% OECD average,  as part of an overall increase in NHS funding 

10.4. The RCGPs calls for an additional 6000 FTE GP’s and 26,000 support staff (e.g. nurses and, receptionists) by 2024, extra training places, a robust recruitment and retention strategy along with formalised practice nurse training schemes

10.5. There should be incentives to attract and keep GPs in less popular, disadvantaged areas

10.6. Practices  on the standard GMS contracts and the less common PMS one, should be supported, and APMS contracts for primary care discontinued.

11.Clinical standards  

Measures must be included to prevent the erosion of clinical practice and standards caused by underinvestment and under capacity.  An example is a Lancet report on the UK’s Covid management, ‘despite international recommendations to the contrary, UK wide, patients were advised to stay at home, book a Covid test, and if concerned consult either an automated online symptom checker or non-clinical triage system. Thresholds for onward referral were high. Equally concerning, the subsequent automated safety net advice given to the patient included ‘how to manage breathlessness at home’ -a practice that would have been inconceivable in 2019.  (6)

12. Specialist services 

12.1.Commissioning of some specialist tertiary services i.e. those rare, exceedingly complex conditions currently commissioned nationally, will pass to ICSs.  There is no obligation on ICSs to continue provision of these services, which could result in a major loss to a group of vulnerable patients for whom there are no alternatives. 

12.2. Devolvement of specialist commissioning should be halted, as with capped ICS budgets, and resource and workforce constraints in small specialisms, these services are more effectively commissioned  by specialist commissioners who understand the disease complexities and delivered in regional specialist centres. 

13. Digitalisation and technology

These are central to ICSs, to reimagine care pathways, with little acknowledgement that the huge and fast shift to virtual and remote consultations, has in many cases, eroded the doctor-patient relationship and continuity, which evidence shows is key to better patient outcomes, not least to reducing mortality.  The blend of remote and face to face consultations needs to be based on achieving better outcomes and reducing inequalities, not as a vehicle to mask staff shortages and under capacity. The emphasis on data driven planning and data sharing between the NHS and LAs, using Population Health Management (PHM), with poor safeguards, and actuarial health targets for the whole population, within a capped budget, are likely to result in further rationing and delays. 

13.1.Face to face consultations and telephone contact, with appropriate advocacy if needed, between health care staff and patients should be enshrined as essential core features of the service, not as rationed/delayed exceptions – Patient First not Digital First.

13.2.Robust safeguards must be included to ensure data sharing is for patient benefit, with high levels of confidentiality protection, throughout the patient pathway. 

13.3.The emphasis needs to shift to a public health approach, not PHM.   

14. Integration – lack of evidence

14.1.Integration ambition underpins the Bill, yet there is no evidence that this Bill will achieve it. Integration is beloved by  governments, but it rarely delivers government  goals, is very difficult to do, and to evaluate. ‘There is no compelling evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity.’ (7)  Even small positive gains  are often dwarfed by a  combination  of other factors influencing health outcomes, and potential benefits are overstated. 

14.2.The most effective integration and collaboration initiatives  are very different from those proposed in the Bill and are: targeted and voluntary; evolve over time; have good governance arrangements; involve organisations with a  shared vision and engage staff. Examples include primary care and public health collaborations for chronic disease management and disease control. 

14.3.Conversely, externally  mandated schemes, as enshrined in the Bill, and differences between the mandated collaborating organisations, can undermine collaboration (8),and this applies, for example, to the NHS and Social Care with their different funding, eligibility, and accountability regimes. 

14.4. The evidence on integration should shape the Bill, and the straitjacket that it currently proposes, be loosened,or scrapped.Ideally there should be a pause and review of better approaches to coordinating and integrating very differently run services,public health, social care, primary and secondary care, in ways that will genuinely benefit patients and health outcomes.

1. D Oliver: Hospital bed numbers were inadequate before the pandemic and will continue to be so. BMJ 2021;374; n1753

2.  Bed occupancy in the NHS. BMA, 8 Sep 2020.

3. (Ola Markiewicz et al.  Threats to safe transitions from hospital to home: a consensus study in NW London primary care. BJGP 2020)

4. (Practices could close or reduce services this winter as pressures mount, warn LMCs. Nicola Merrifield, Pulse 3 August 2021)  

5. (Mirror, Mirror 2021: reflecting poorly. Commonwealth Fund)

6. D. Goyal, C. Millar, D. Burke. Restricted access to the NHS during the COVID-19 pandemic: is it time to move away from the rationed clinical response? The Lancet Regional health -Europe -8(2021) 100201

7. National Audit Office 2017, Health and Social Care Integration.

8. Impacts of collaboration between local healthcare and non-healthcare organisations and factors shaping how they work: a systematic review of reviews. Hugh Alderwick et al, Health Foundation et al. BMC Public Health, (2021) 21:753

 

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