by Brenda Allan & Alan Morton
In the next few days, the Government plans to place before Parliament the White Paper – Integration and Innovation that will formally establish Integrated Care Systems (ICS) across England. As this is just before the end of the Parliamentary Session, there will be no effective scrutiny of its provisions.
While the goals of the White Paper – promoting integration, partnership and collaboration- may seem laudable, it fails to address the real keys to improving health outcomes in England.
Staffing and Funding Crisis
The NHS is suffering a severe staff shortage and inadequate funding: according to its own figures the NHS lacks over 100,000 staff while across the service it has racked up £1 billion worth of debt. The National Audit Office has reported that the NHS is not on a sustainable financial footing.
- There should be a full public consultation involving all stakeholders, with implementation delayed until after the worst of the pandemic, as suggested by NHS Providers.
- There is an urgent need for increased NHS funding to meet the backlog that existed before the pandemic, and has been exacerbated by it, and for the restoration of annual funding increases of 4%.
No public representation but private companies on ICS Boards
The ICS NHS Board membership comprises a chief executive, a nursing director, a medical director, and a minimum of two other independent executive directors. NHS England also expects that boards will have three additional partner members, including one from the local NHS, one from general practice and one from social care. The ICS NHS board controls plans and budgets for the whole system.
There is no mention of representation for patients and public. There is no requirement that ICS Boards meet in public, that Board papers and minutes should be published, or that they should be subject to Freedom of Information (FOI) requests. As private providers can be members of ICS boards this is an unsurprising but retrograde step for a public body.
For example, the Bath, North East Somerset, Swindon and Wiltshire ICS has a Virgin Care director on their Partnership Board. Virgin Care was not prepared for any information to be shared with the public. In response, the other board members agreed that the ‘open book’ approach would need to be amended to protect providers’ corporate and commercial interests.
- Councils and primary care should have parity of representation and voting rights on the main ICS NHS board, or at the very least, increased voting representation.
- Measures need to be in place to ensure that ICSs are fully accountable to councils, public, and patients: meetings should be held in public and minutes and papers made public. ICSs should be subject to FoIs.
- Independent providers should be excluded from membership on decision-making and resource allocation ICS boards and committees.
- The role and remit of Joint Health Overview and Scrutiny Committees should continue if and when ICSs are formally constituted
Contracts for private providers
The White Paper proposes to scrap the 2012 Health and Social Care Act that effectively forces NHS organisations to run a full procurement and tendering process for many contracts within the NHS. This is the legislation that many feel is responsible for an increase in privatisation of the NHS. Instead, the NHS will be able to decide whether a full procurement process is needed based on circumstances.
However tendering can still take place and private companies can still be awarded contracts in the NHS, just as they were before the 2012 Health and Social Care Act. With private independent providers permitted on ICS Boards, there is potential for major conflicts of interest as highlighted by the BMA who say, “..the White Paper takes the first step to abolishing these wasteful rules, but unless it goes further – making the NHS the default option for delivering NHS services – there is a risk that contracts will be awarded without scrutiny to private providers at huge expense to the taxpayer, as was seen with the procurement of PPE and Test & Trace during the pandemic”.
Following the removal of the current procurement requirements a new Provider Selection Regime (PSR) consultation document proposes that contracts should be permitted to continue, creating opportunities for private companies, (like Centene) to ‘lock in’.
There is a developed, private health care sector of 200 plus, pre-approved companies in NHS England’s Health Support Service Framework.
- NHS organisations should be the preferred providers
- ICSs should use the provisions in the PSR to continue or directly select existing NHS, and some not for profit providers, when contracts come for renewal, as these are better value for money, with no funds diverted to profit and contracting costs, and all funds reinvested in the service.
- The remaining elements of the expensive and wasteful private market tendering provisions should be abolished.
Social care and local authority control
Major proposals to deal with the funding crisis in social care are deferred again.
The Discharge to Assess guidance for the arrangement in advance of funding and support for people leaving hospital – some of whom require social care – will be updated. Assessments will take place after discharge from acute care, with an estimated 80 per cent of patients not receiving an assessment.
Local councils’ responsibilities for social care have already been eroded by the Care Act Easements 2020, and now the Secretary of State will be given powers to make direct payments to social care providers and the Care Quality Commission will gain new powers to assess local authority delivery of Social Care.
The plans for Public Health are sparse and mainly relate to restrictions on food advertising and labelling to tackle obesity.
- There should be increased investment in social care and public health, with wholesale reform of the former, to deliver significant improvement to health outcomes and inequalities.
The Secretary of State can remove a profession from regulation, and abolish regulators. This opens the way for employment of a less skilled, lower paid workforce with poorer health outcomes for patients.
- There appears to be no merit to these proposals and they should be scrapped.
Virtual care replaces quality care
Digitisation and technology play an important part in the Act. ICSs are required to re-imagine care pathways with little acknowledgement that the huge shift to virtual and remote consultations erodes the doctor patient relationship that is key to better patient outcomes and indeed to reducing mortality.
The emphasis is on data driven planning between the NHS and local government using Population Health Management (PHM) and data sharing, (with poor safeguards) and actuarial health targets for the whole population.
This is to be done within capped budgets that will result in even more serious delays and rationing, coming as it does after years of low annual funding increases; the impact of Covid 19; and NHS England’s latest demand for savings, increased productivity and efficiency, and the restoration of ‘normal financial disciplines’.
- Patient First not Digital First – increase investment to ensure a clinically appropriate mix of face to face and digital contact rather than an over reliance on digital contact driven purely by costs.
- Introduction of capped budgets should be scrapped or delayed.