On 12th September NHS England held a badly-publicised event in Leeds as part of its public consultation on its new Accountable Care Organisation contract – which it recently renamed the Integrated Care Provider contract.
NHS England announced the Integrated Care Provider contract consultation on an obscure corner of their website on 3rd August – a Friday, in the first week of the Summer Holidays when Parliament is not in session. It will run until October 26th.
(This is a long read, sorry – about 4,400K words. But the short summary – Key Points of Discussion – gives the gist of what was said at the Leeds consultation event.)
10 NHS England staff attended. The two who spoke were Ali Sparke, who led the event, and David Savage.
Ali Sparke described himself as an NHS England Deputy Director – but his Linked In profile says he is Head Of Contracts and Business Environment, New Business Models Team. He has been there for a year and a bit and before that was a Senior Manager at Ernst and Young for nearly 11 years, working on healthcare.
David Savage, is NHS England Legal Lead on NHS standard contracts. He works on the Integrated Care Provider contract and new business models. He was one of the NHS England legal team in court for the Professor Pollock/Stephen Hawking Judicial Review of the Accountable Care Organisation contract (JR4NHS).
14 members of the public took part – including people from:
- Stockport NHS Watch
- Defend Our NHS Wirral
- 999 Call for the NHS
- North Kirklees Support the NHS
- Leeds Hospital Alert
- Leeds Keep Our NHS Public
- Defend Our NHS York
- Mental Health Action York
- S Yorkshire and Bassetlaw NHS Action Group
- Doctors for the NHS.
Other members of the public included two lay people from the BMA patient liaison group, someone from SpaMedica ophthamology company and a retired consultant anaesthetician from Staffordshire who is also something to do with Dudley Multispeciality Community Provider.
Key points in the discussion
There shouldn’t be ANY contracts in the NHS – it should not be run as a market. Full stop.
The Integrated Care Provider contract is just tinkering with the legislation that created the purchaser/provider split, opened the NHS to competitive tendering and fragmented it by ending the Secretary of State for Health’s responsibility for the NHS as a whole.
Given that it is being challenged in the Court of Appeal and so might not even be lawful, why is NHS England consulting on it now? What’s the rush? Why are they consulting on a contract that may not even be lawful?
David Savage said NHS England brought the consultation forward as a result of the Professor Pollock’s and Professor Stephen Hawking’s JR4NHS judicial review, because of the need for transparency. The downside is that what they’re consulting on is less developed.
Re the 999 Call for the NHS Appeal, he said that the further they defer consulting to wait for the outcome of the Judicial Review, the more they could have been accused of failing to honour the decision to consult.
(I don’t think so.)
“The outcome of the Appeal will have a bearing on the decision about whether we proceed with this policy and on what basis.”
None of the members of the public had a positive word to say about the contract throughout the meeting, that overran by 30 minutes.
Even if you were to accept the premise that contracts are needed in the NHS, the Integrated Care Provider contract is a pig’s ear:
- It wouldn’t make any difference to patients.
- It’s driven by NHS England’s cost-cutting agenda to avoid a projected £22bn funding shortfall by 2020/21
- It would endanger the training of junior doctors.
- It carries a risk of increased privatisation that NHS England is sweeping under the carpet
- NHS England downplayed the importance of the Integrated Care Provider contract
(So why have they fought two Judicial Reviews to defend it?)
- It’s not clear why the Integrated Care Provider contract is even needed
- The contract’s complexity is a big risk factor
- The Integrated Care Provider contract is based on the Vanguard models of Primary and Acute Care Systems, and Multispecialty Community Providers – but there’s no evidence they work.
- NHS England have their knickers in a twist about commissioning responsiblities under the the Integrated Care Provider contract.
- There’s nothing in the Integrated Care Provider contract about how to integrate NHS and social care
- The consultation is rubbish
NHS England admits the Integrated Care Provider contract wouldn’t make any difference to patients
Ali Sparke started by explaining the current market-based NHS works by means of contracts between commissioners and providers. These specify the type of care bought. This is done using the NHS standard contract and 3 GP services contracts. As a patient moves through the system they can go to various providers. The Integrated Care Provider contract would make a single contract for all providers.
This led a member of the public to ask:
WHY WOULD A SINGLE CONTRACT MAKE ANY DIFFERENCE TO PATIENTS?
Ali Sparke said it would make no difference to patients – but it would provide an opportunity for a single provider to make a decision about the needs of the population and how to meet them better.
A member of the public objected that NHS England’s plan is for multiple SUBCONTRACTS within the Integrated Care Provider contract, so that argument makes no sense.
Another member of the public said that it was on the grapevine that the acute hospital trust in Barnsley will pick up the Integrated Care Provider contract. But they have no expertise in community and mental health services. That creates problems. The actual reality for patients and carers is that a single provider with no skills in all areas is not going to help.
The problem is the processes the managers create – eg appointment letters that say if you don’t turn up you’ll be discharged.
The Integrated Care Provider contract is driven by NHS England’s cost cutting agenda to avoid a projected £22bn funding shortfall by 2020/21
But NHS England failed to mention the cuts agenda at the heart of the Integrated Care Provider contract.
Ali Sparke stated that integrated care was a focus of NHS England’s 2014 Five Year Forward View, which is based on Whole Population Health models.
(What he didn’t say was, that the Five Year Forward View’s objective was to set up cheaper “care models” for treating patients with chronic health problems, because of a projected £22bn funding shortfall by 2020/21. The Integrated Care Provider contract is designed to deliver these cheaper care models. That is a massive problem as far as patient care goes.)
I asked about the NW London community services contract that is too cheap to pay for safe services, so local NHS trusts have not bid for it. So this contract is unlikely to provide safe services.
Ali Sparke ignored the question.
One of the Defend Our NHS York people asked, When allocating a contract, which comes first – needs or money?
Ali Sparke said bidders have to stick within budgetary limits.
David Savage said, The Clinical Commissioning Group says “This is our budget.” Then potential providers propose how they’d spend the money. Ultimately there are budgetary constraints. It’s about meeting the needs of the population within that budget.
A member of the public said, It used to be based on 80% quality, 20% costs.
David Savage said that Clinical Commissioning Groups would evaluate bids in competitive tendering against criteria they’d set. Clinical outcomes would be part of the contract.
Members of the public pointed out that the cost-cutting contract endangered the training of junior doctors
Someone asked how commissioning for allowing junior doctors to train was going to be written into the Integrated Care Provider contract. She pointed out that it’s not just about patients. There’s a shortage of all sorts of specialities and it’s vital that Junior doctors and other staff are allowed to train.
Ali Sparke replied that the Integrated Care Provider and NHS Standard Contract don’t talk about training because Health Education England deals with that.
The member of the public asked:
“Health Education England will have to fit their trainee doctors within this system then?”
Colin Hutchinson said this point is vital – Health Education England pay some of the cost of training junior doctors, but the rest has to come from the provider organisation. The output of a doctor in training is less than a qualified doctor, so from the provider’s point of view it’s not attractive to offer doctor training. There’s no compulsion on providers to provide that training – there needs to be built into the Integrated Care Provider contract a requirement to contribute to the training of the national workforce.
Ali Sparke replied that doctors themselves will be employed by providers. The Integrated Care Provider contract will only affect training in that it affects how doctors work.
The Integrated Care Provider contract carries a risk of increased privatisation that NHS England is sweeping under the carpet
Stockport NHS Watch asked how NHS England are going to make sure that predatory bids are going to be dealt with, related to contracts with private providers – how is NHS going to be put in a position where it can bid fairly for services?
Ali Sparke said they can’t say any contract in the NHS can only be held by a public body or NHS organisation. Commissioners have to treat all providers equally and assess only on the basis of their ability to deliver the contract.
But local NHS organisations are the ones with the desire and ability to hold an Integrated Care Provider contract.
It’s the Clinical Commissioning Group’s responsibility to make sure there’s a provider that can deliver a safe contract.
Defend Our NHS Wirral said that the private sector is to play a role in the Sustainability and Transformation Plan. It involved 2 USA companies, including Cerner. And there are 2 GP Federations, the majority in LLP Peninsula Health, with Virgin Care as a partner . This federation has been developing the primary care model. He asked,
“How confident can we be that in 5-10 years Virgin Care won’t be running an Integrated Care System in Wirral?
Ali Sparke said that the experience from places they’ve talked to is that NHS organisations are in the best position to get Integrated Care Provider contracts.
He added that they don’t have any evidence that any other organisation than the NHS will hold a contract, but they have built transparency considerations into Integrated Care Provider contract, eg the business plan must beshared with Clinical Commissioning Groups etc.
This includes contract management that if a non-NHS organisation were to hold an Integrated Care Provider contract, they can’t spend the money if they’ve not met the core requirements of contract. But he admitted this isn’t included in the main Integrated Care Provider contract.
Someone from S Yorkshire and Bassetlaw NHS Action Group asked if there was any safeguarding if one organisation were to run all the locality Integrated Care Providers in one area.
Ali Sparke: It’s clearly for local Clinical Commissioning Groups to decide what’s appropriate checks and balances across the way.
David Savage said he took on board concerns that if the same providers start to dominate market that could be cause for concern.
Ali Sparke said if a monopoly started emerging they would have to look at it, but he didn’t think that was likely.
I said it seemed highly likely to me. What about Modality? West Yorkshire and Harrogate Integrated Care System is looking at 40 Primary Care Homes. That is potentially 40 Integrated Care Provider contracts that Modality could hoover up.
Ali Sparke said he didn’t know about either of those things.
Spa Medica (an ophthamology company that gets a lot of NHS work in Wakefield, Kirklees and Calderdale), asked if a partnership can apply for an Integrated Care Provider contract.
Ali Sparke: One legal entity has to hold the contract, but lots of providers can come together to decide which provider will bid.
(He didn’t point out lots of providers could come together to form a joint venture or special purpose vehicle.)
York Defend NHS asked:
Where is this leading to? It’s a bid to bring in the private sector to NHS. Where does mental health stand? The private sector’s going to come in. The Voluntary and Community Sector is being introduced into mental health servics and replacing statutory mental health services. Should they be doing this? And they’re suggesting that people with mental health problems would benefit from a cup of tea and a chat. York mental health services are shrinking by the moment, this is not acceptable.
The NHS England bods said nothing.
Kevin Donovan said he was worried about the basis of some thinking on the Integrated Care Provider contract. He asked how much is derived from PWC and McKinsey, pointing out that cuts for his local Sustainability and Transformation Plan were done on the basis of a report from PWC. But PWC has been lambasted widely. He doesn’t feel confident that the Clinical Commissioning Group and Council understand what’s happening, so they rely on such management consultancies.
Ali Sparke said nothing. (Perhaps because he was employed by EY for eleven years immediately before working as Head Of Contracts and Business Environment in NHS England’s New Business Models Team.)
NHS England downplayed the importance of the Integrated Care Provider contract
(So why have they fought two Judicial Reviews to defend it?)
Challenged by Defend our NHS Wirral that contracts are not a solution to patient care issues, but are at the root of the problems in the NHS as a result of the 2012 Health and Social Care Act, Ali Spark deflected the point by downplaying the Integrated Care Provider contract:
“All that this proposal would potentially result in is a different option for CCGs to use if they thought appropriate.”
I asked, What about the pressure that Sustainability and Transformation Partnerships will become Integrated Care Systems?
Ali Sparke said,
“Integrated Care Systems – Clinical Commissioning Groups and Providers coming together – are different from Integrated Care Providers.”
Later he added that NHS England has developed the new Integrated Care Provider contract because there was a collaborative approach by local NHS organisations to overcome barriers, eg through Integrated Care Systems. And local NHS organisations have told NHS England that different contracts with different providers can be rigid and prevent collaboration, so they want different sets of services to be bought from one provider in the same way.
So according to Ali Sparke, Integrated Care Systems are a step on the way to Integrated Care Providers – which is anyway what NHS England stated in its Five Year Forward View Next Steps (before it rebranded Accountable Care as Integrated Care):
“In time some Accountable Care Systems may lead to the establishment of an Accountable Care Organisation.”
David Savage claimed that discussion between commissioners and providers in a local forum may result in a decision to adopt an Integrated Care Provider. That would be a local decision.
But a member of the public disputed that it would be a local decision: in South Yorkshire and Bassetlaw there are already protocols that have to fit in with Integrated Care System protocols – so in areas that are already Integrated Care Systems, Clinical Commissioning Groups are no longer autonomous.
Barnsley is going down the Integrated Care Provider route now and however they use it, they have to fit with the Integrated Care System. And if they don’t, they won’t get their full allocation of money.
Why is the Integrated Care Provider contract even needed?
I said that early this year, after NHS England said no one could use the Accountable Care Organisation contract until further notice (pending the contract consultation), Scarborough and Ryedale Clinical Commissioning Group translated a Multispeciality Community Provider contract it had awarded, that was due to go live in the spring, into the NHS standard contract.
So why introduce the Integrated Care Provider contract if everything it does can be done with the NHS Standard contract?
“It’s mostly true that there are minor changes to make the contract suited to the kind of care we want to offer. It’s not a radical change.”
So why is it subject to the Integrated Support and Assurance Process for “complex contracts”? (see next section)
I disputed that. I said the complexity of system-wide contracts are beyond the Clinical Commissioning Groups , eg the Integrated Urgent Care Services contract for Yorkshire and Humber. The lead commissioner is having to pay the consultancy company Attain to tell them what to do.
Ali Sparke didn’t answer this.
Colin Hutchinson said
“It opens the door to the provider underbidding for a contract they know they can’t deliver and then coming back later in day for more money, because the chaos of an Integrated Care Provider collapse would be unacceptable.”
The complexity of the Integrated Care Provider contract is a big risk factor
Colin Hutchinson (Doctors for the NHS) also pointed out that the track record for well drawn up complex contracts is not good when you look at the big Cambridgeshire and Peterborough community health and old people’s services contract, Staffordshire cancer services and the east coast main line contract.
The risk of going down this contractual route is that it doesn’t have the flexibility that public professional service used to have.
Ali Sparke said that NHS England’s and NHS Improvement’s Integrated Support and Assurance Process will happen at different points in commissioning these contracts. This is a process for complex contracts.
The Integrated Care Provider contract is based on the Vanguard models of Primary and Acute Care Systems, and Multispecialty Community Providers, but there’s no evidence they work
David Savage said,
“Dudley Clinical Commissioning Group have come to the conclusion that a single contract of this sort for out-of-hospital services is what they want to pursue. We speak to them daily. Whether they can use the Integrated Care Provider contract will depend on outcome of the consultation and Judicial Review process.”
But neither he nor Ali Sparke answered a question about what Dudley people think of the Dudley Multispecialty Community Provider Vanguard.
Kevin Donovan asked about the state of Russell Halls hospital in Dudley – where an investigation has recently been launched into a reported 54 deaths over a six-month period, “just 24 hours after a damning inspection revealed conditions at the hospital were so bad some staff would not even take their own families there”, according to the local newspaper.
His question was ignored.
The NHS England lot didn’t mention the National Audit Office report on Vanguards , either.
The report said that there’s been no consistent approach to evaluating the Vanguards and there’s no conclusive evidence about what’s worked. Unless NHS England continues an evaluation after implementation of the cost-cutting care models is complete, no one will know what their long term impact has been.
It also says most Vanguards have ditched the idea of using the Accountable Care Organisation contract (now renamed Integrated Care Provider contract) in favour of a consensus- based non-legal agreement between partners. (Which ties in with our questions about, why is the Integrated Care Provider contract even needed?)
In terms of Vanguard outcomes, the evidence is unclear. The National Audit Office report cites some evidence that the growth of emergency admissions has been slower in Vanguard areas than elsewhere, but says there are data quality and other issues that make it hard to evaluate the effect of the Vanguards. The report also notes a bigger reduction in demand for hospital beds in non-Vanguard areas than in Vanguard areas, and says that NHS England claims this is because Vanguard areas did not reduce elective care bed days to the extent that non-Vanguard areas did. The NAO is not sure that this is an accurate explanation.
NHS England have their knickers in a twist about commissioning responsiblities under the the Integrated Care Provider contract
Ali Sparke said NHS England don’t want to replicate the role of a provider that holds lots of contracts, instead of the Clinical Commissioning Group. The Commissioner needs to think through how the Integrated Care Provider operates and works with other contractors.
He asserted that the Provider having direct conversations with other subcontracted providers would be better than the commissioner having such conversations. (But he didn’t say why)
Members of the public pointed out that there is confusion about how the Clinical Commissioning Group would hold an Integrated Care Provider to account.
Colin Hutchinson (Doctors for the NHS) said that at the moment, Clinical Commissioning Groups have to carry out needs assessment. They will still have responsibility for having needs assessment done – but the consultation doc suggests the Integrated Care Provider can do it for the Clinical Commissioning Group.
The Integrated Care Provider can also submit data analysis to show if they’ve improved matters. There is too much scope for the Integrated Care Provider to tailor the needs assessment to what they can provide with money, and then letting them mark their own homework.
Ali Sparke admitted,
“It’s true we want providers to take a greater role in needs assessment but it’s not saying Clinical Commissioning Groups don’t have a role in holding the provider to account and understanding the needs of the population as a whole.”
Colin Hutchinson: But this self certification process suggests weakness.
David Savage said he wasn’t sure it would work like that. He said that the Integrated Care Provider does more needs assessment, because of its role in meeting the needs of the whole population. The statutory duties of the Clinical Commissioning Group remain – how they perform that role changes. So it becomes more a strategic role in determining population needs.
I said that seemed self contradictory to me. What is the difference between needs assessment and determining population needs? They sound like the same thing.
Ali Sparke said that there is a role for Clinical Commissioning Groups around equality and health inequalities and how the Integrated Care Provider contract will tackle these issues.
He also said that it’s an integrated budget and the contract gives the provider the budget with discretion to spend on preventive measures to improve long term population health outcomes.
Has he read Ted Schrecker’s recent commentary in Critical Public Health on the Commission on Social Determinants of Health, ten years on?
This points to the inadequacy of the predominant individualised, biomedical understandings of health and illness, and the need to address the difficult politics of growing economic inequality, which is the underlying cause of health inequality. Not something either Clinical Commissioning Groups or Integrated Care Providers would be in a position to do.
Ali Sparke said that the Clinical Commissioning Group retains its role in holding providers accountable. That might happen differently because the Clinical Commissioning Group would hold one provider to account instead of many.
David Savage claimed it would be good for patients to know that there is one provider responsible for their care. But didn’t explain why.
Spa Medica – an ophthamology company that does a lot of NHS work in West Yorkshire, was more interested in whether the Integrated Care Provider contract includes bits about how the contract holder will work with other providers
David Savage said no.
SPa medica asked, Would existing providers as part of a pathway be decommissioned?
David Savage said, Possibly.
Ali Sparke: Most of those providers have specific expertise in delivering those services so it’s unlikely that a new provider could come in and replace them,
Spa Medica: Is it like a prime provider model?
Ali Sparke: yes.
There’s nothing in the Integrated Care Provider contract about how to integrate NHS and social care
But NHS England has been banging on about how this is one of its big goals.
A member of the public asked:
What about social care? It’s in a state of collapse, hugely underfunded. Who pays for it? It’s not free at point of use like NHS. How has this been thought through? And it’s under democratic control – but if it moves into NHS control that ceases to apply.
Ali Sparke replied that Local Authorities and Clinical Commissioning Groups would decide how much social care and social services should be commissioned through this contract. He added,
This is up to a local decision. Whether through an Integrated Care Provider or NHS Standard contract, the Local Authority remains accountable for those services and the Local Authority and Clinical Commissioning Group will have to agree the accountability processes. The contract won’t changes the accountability of the Local Authority for providing those services.
Colin Hutchinson said,
The Integrated Care Provider contract is a variant of the NHS Standard contract, but I can’t see much in the Integrated Care Provider contract that’s applicable to the provision of social care services. Even if I agreed with the initial premise of contracting, I can’t see it’s fit for provision of social care services.
David Savage said,
We’ve been talking with the Local Government Association and stuff in the Integrated Care Provider contract includes stuff from those discussions. But it still looks very much like an NHS contract because there’s no national standard template for a Local Authorities’ social care services contract. Local Authorities in that engagement exercise raised various issues for the social care provider market. We tried to put their concerns into the Integrated Care Provider contract but there’s a significant way to go. But it will only be in the testing of the contract that the degree of detail about Local Authority commissioned services will come out.
Initially NHS England had planned to test the contract first and then base consultation on that. We have brought that forward.
Colin Hutchinson said that the Local Government Association has been quite scathing about the Sustainability and Transformation Plan process. He asked if they are they more satisfied about the Integrated Care Provider contract now?
The consultation is rubbish
A member of the public pointed out this consultation is hidden on the NHS England website, there was no press publicity. And nothing in NHS England’s In Touch
bulletin. The NHS Citizen staff member present said nothing.
Ali Sparke said they had tried to reach out through local organisations
The member of the public pointed out that NHS England have to consult with the PUBLIC, not such groups.