What changes will patients notice when the NHS is run by Integrated Care Systems and Providers?

As of April 2019, there will be 20 Integrated Care Systems in England.

Source: Presentation to Middlesbrough Health Scrutiny Committee, 13.11.18

By April 2021, Integrated Care systems are to cover the whole of England

These successors to Sustainability and Transformation Partnerships are intended to “manage demand” for NHS services, following a cost-cutting blueprint from the USA’s Medicare System of Accountable Care Organisations.

It hasn’t worked in the USA and it’s not an appropriate model for the NHS – one of the industrial world’s cheapest and most efficient and effective health services. The aim of ‘managing demand’ means that patients will experience some quite radical restrictions to our access to NHS services – but NHS England claims that innovative ways of integrating services will be more efficient and cut costs, implying that this means the NHS will still provide “care for all.”

This is unlikely, in the light of recent reports from the National Audit Office and the Nuffield Trust. They show there is little or no evidence that – where they’ve been trialled and introduced – these innovations have either cut costs or improved services.

Kieran Walshe, professor of health policy and management at Alliance Manchester Business School, the University of Manchester, reckons he knows why:

“…to get the money for innovations from NHS England, the Department of Health and Social Care or whoever, organisations must promise to achieve … improbable outcomes, and so healthcare leaders (and the people doling out the money) engage in a mutual exercise of magical arithmetic.
Dubious assumptions are made about the cost improvements to be had from acute care reconfigurations, or the way community care improvements will reduce demand for acute inpatient beds and release cash savings. Often, nobody goes back to check if the sums were right. Anyway, by then the money has been spent…
Ask people on the ground about what’s going on and you often get a very different picture from the one you hear in the steering group reviews. What can most diplomatically be described as cognitive dissonance abounds.

https://www.hsj.co.uk/innovation/how-do-we-know-what-works-in-the-nhs/7024238.article

Integrated Care Systems – sorting the deserving from the undeserving sick

Integrated Care Systems will impress on patients that we must not rely on what the Integrated Care System zealots call a “dependency” model of healthcare – ie, you get ill and you hope someone skilled and qualified will help you get better, deal with an incurable condition, or ease your passage out of this world, whichever it is.

Instead we must take part in behaviour change schemes, adopting healthy behaviours that reduce the risk of succumbing to so-called preventable illnesses such respiratory diseases, cardiovascular disease, obesity, diabetes, cancer, depression, anxiety and so on. This is despite the fact that such illnesses are strongly associated with socio-economic deprivation. That’s what our government needs to tackle, along with improved regulation of food, air pollution, climate change, transport and housing.

In this way conditionality will be imposed on our access to healthcare, creating a distinction between the deserving and undeserving sick.

The welfare/benefits system already punishes people who receive ESA and PIP: it makes them more ill than they were, by sanctioning them or making mistaken decisions to stop benefits on the grounds that they are fit for work. The integration of job centre and GP practices is blurring the lines between controlling ill health and treating ill health.

The official blurb is that Integrated Care Systems and Providers will “wrap services around patients” – particularly those of us with complex needs, at the end of life and women using maternity services. So that we don’t have to be sent hither and yon to various departments and services, to piece together all the bits of treatment and care needed in such situations.

This is clearly a good idea, but doesn’t require an Integrated Care System or Provider – as former Lewisham Hospital consultant Tony O’Sullivan told the Health and Social Care Select Committee at its inquiry into Sustainability and Transformation Plans and Accountable Care Organisations last year.

Private and third sector community care providers

Many “wrap around” services in the “community” and “closer to home” will be provided by private companies or third sector organisations.

The danger of relying on private or third sector providers is illustrated by the recent collapse of a social enterprise maternity service in Waltham Forest , East London

Regardless, such reliance is built into the “Better Births” Integrated Care Systems. 44 of these so-called Local Maternity Systems have been set up following the National Maternity Review, which advocated a new model of maternity care.

Maternity services campaigner Jessica Ormerod explains:

“It emphasises community care delivered through local hubs with a theoretical reduced demand on hospital services. It recommends an increase in independent sector providers and introduces Personal Care Maternity Budgets. Personal Care Budgets commoditise and monetise the system. They add layers of unnecessary complication, increase expense, fragment accountability and lead to an accounting nightmare.

44 Local Maternity Systems have been established. The systems have been introduced without consultation, peer review, pilot studies or effective oversight from public health or parliamentary scrutiny. They are small-scale Integrated Care Systems.”

West Yorks and Harrogate Integrated Care System has set up a “Better Births’ Local Maternity Service And now the closure of Pontefract Hospital Maternity Unit (Friarwood Birth Centre) is threatened. Is this the result of the “reduced demand on hospital services” that the National Maternity Review theorised? Or just another cut?

Update 18.11.21 Pontefract Hospital Maternity Unit was “temporarily”closed from Friday November 8 to September 30 2020, on safety grounds because there were not enough midwives to staff it. The current Mid Yorks Trust maternity services webpage shows that Pontefract Hospital now only provides an antenatal day clinic. So the temporary closure of the hospital’s Friarwood Birth Centre seems to have become permanent.

Means-tested personal health budgets for care closer to home

As hospital services are centralised, cut and moved out into large scale GP and community health services networks and hubs, the official blurb is that patients will be cared for “closer to home”. Patients’ beds at home will be considered as “hospital beds at home.”

Care at home for patients with long term illnesses will increasingly be bought individually by patients through personal health budgets – with some of the money provided by the NHS and social care, some coming from the patients themselves.

Patients’ entitlements to personal health budgets are assessed by Multidisciplinary Teams. Guess what? Barrister David Lock has found that Clinical Commissioning Groups (who have to fork out the money for the NHS bit of personal health budgets) are trying to get Multidisciplinary Teams to change/downgrade their assessment of patients’ Continuing Health Care needs and entitlements. Even though this is unlawful.

Mandatory large scale GP networks for 30K- 50K+ patients

By this summer, GP practices will be forced to become part of large scale GP networks. Each network will be centred around one GP and community health services hub.

The new large scale GP networks will be largely staffed by new grades of less skilled clinical staff – many copied from the workforce in USA accountable care organisations. And they will rely considerably on charities and other third sector organisations. Only patients with complex needs will see GPs.

Many GP patients will be handed “social prescriptions” to go and join a community group, contracted for the purpose by the local Clinical Commisioning Group. The idea is that will help them sort out non-medical problems that are damaging their physical or mental health.

No matter that this damage is caused by government policy failures in a whole slew of areas – social security (if only), economics, jobs, environment, housing.

Apparently it is our individual responsibility to make good the systemic damage to our health, with the help of voluntary organisations.

The new large scale GP and community health service networks and hubs will use digital health technology (so called telehealth and telecare) together with shared electronic patient records to identify patients who are at risk of admission to hospital through A&E and prevent their unplanned hospitalisation.

But Kieran Walsh, professor of health policy and management at Alliance Manchester Business School, the University of Manchester, points out that

“expecting integrated care to reduce demand for hospital accident and emergency services makes about as much sense to me as thinking it might reduce the consumption of fast food, or increase the uptake of ballroom dancing lessons.”

Urgent care

Access to urgent care will be through an Integrated Urgent Care Service. These are to be up and running everywhere in England by April 2019. A revamped NHS 111 service will hand patients off to a phone- and digital-technology based Clinical Advice Service.  This aims to complete the consultation without referral to other services.

Integrated Urgent Care Services (described as the “front door to the NHS”) are key to the Accountable/Integrated Care drive to replace skilled NHS staff with digital technology  – to the profit of life sciences and digital technology companies.

The Integrated Urgent Care Service will fundamentally restrict patients’ direct access to a whole range of NHS services and will benefit the corporate profits of digital technology companies – not patients or NHS staff.

This is going to be a feature of patients’ experiences of the NHS.

Integrated Care Systems require massive NHS purchase of digital technology to collect and share patient data for accountancy and other purposes

Our bodies will become the source of data harvesting for sale to commercial companies.

Our medical data will also be used to calculate Integrated Care Providers’ contract payments, on the basis of whether or not various outcomes are achieved through providing patients with health care.

These so-called population health outcomes are a key factor in determining “risk/reward” payments to Integrated Care Providers. If they spend less than the lump sum payment they have received from the Commissioners, they are rewarded with being able to keep some of the unspent money. If they spend more – tough, they have to carry the risk.

Nice. Accountancy decisions will compete with clinical need as doctors decide what treatments to give which patients.

Patients will increasingly “self care” through the use of digital apps and online information about managing their ailments.

Increasingly clinicians – particularly in the new large scale GP and community health services networks and hubs – will use digital clinical decision making tools to diagnose patients’ illnesses and decide on the appropriate course of treatment.

These clinical decision making tools will automatically indicate which hospital treatments are no longer routinely funded by commissioners, so that clinicians will have to apply to the commissioners for prior approval or an individual funding request, before they can refer patients on to secondary care.

Referrals will increasingly be mediated by a referral management centre that decides whether or not to approve the referral.

Standardised care pathways

Standardised care pathways will determine treatment for various conditions. GPs may be unable to refer patients onto these pathways. Instead patients are likely to have to ask for an appointment with a private company to assess their care needs, as is already happening with MSK and pain services in many areas.

The standardisation of care that clinicians are centrally required to provide in Integrated Care Systems seems like the imposition of the National Curriculum in schools. Before, teachers were trusted to use their skills, knowledge and creativity to teach in a way that best suited their students. But machine learning, which is where education is going, needs everything to be standardised so it can be performed by algorithms and robotisation. The same process is taking place in the NHS, with the aim of substituting digital for human care to the greatest extent possible.

Standardised pathways such as diabetes are subject to creeping privatisation through the control and provision of technology. In the past, new devices like insulin pens and finger prick monitoring systems were delivered by the NHS with little or no patient contact between pharmaceutical companies and the patient. Today private companies are increasingly delivering the technology directly. Literally, as you order supplies on the phone and they are sent to patients in the post – via typically new and poorly trained staff that treat the delivery of a life giving device the same as when private companies deliver a TV or a toaster.

Corporatisation of healthcare is dehumanising

In 2009 GP Dr Jonathan Tomlinson explained how corporatisation of healthcare – already taking off in the NHS under the New Labour – is dehumanising for both patients and doctors,

“[R]eal, whole people living with their hopes and worries, ideas and expectations, are broken down by the process of corporatisation into biological parts…so that they can be measured and converted into profits…

“The UK government is trying, through the purchaser provider split and the provision of APMS contracts, to create primary healthcare markets.

“Markets depend on identifiable commodities that can be bought and sold, so markets in healthcare depend on breaking down complex health into simple commodities…

“The markets for preventative services (screening, statins) are greater than those for curative services because far greater proportions of the population are ‘at risk’.  This results in a shift of emphasis from cure to prevention, i.e. from treating the ill, towards treating the well.

“Profits are increased by the invention of new services (screening and other investigations) and commodities (new diseases or risk factors).

“These last 2 points are examples of ‘disease mongering’.”

Patients not Profits. How Markets dehumanise health.

Hospital cuts and centralisation

Hospital services will be cut and centralised. District General Hospitals will vanish, replaced by acute and emergency hospitals, planned care clinics and a few specialist hospitals. Increasingly, planned care surgery will be carried out as day cases without overnight stays. Patients will have to travel further to receive both acute and emergency and planned hospital treatment.

Unaccountably, patients leaving acute or planned care hospitals who need rehabilitation will find that community hospitals set up for that very purpose have closed. So where will they go if they are not ready to go home because their care needs are too great while they are convalescing?

#Justice4NHS

These are all reasons why 999 Call for the NHS continues to seek #Justice4NHS, with an application to the Supreme Court to review the Integrated Care Provider contract, after the Court of Appeal rejected our appeal to overturn the High Court ruling against our Judicial Review.

(Update: The Supreme Court refused the appeal. Leaving us to continue the fight against the imposition of US accountable care on the NHS outside the courts. )