New NHS Primary legislation will fragment the NHS into local Accountable Care Organisations – now rebranded as Integrated Care Providers
New NHS Integrated Care Provider Trusts will turn the NHS into a set of local private/public partnerships. The “health support services” providers such as Optum will set up and sell the data and analytics systems required by Accountable Care Organisations aka Integrated Care Providers. As lead provider of a whole range of health and social care services for its area, the NHS Integrated Care Provider Trusts will subcontract many front line NHS, social care and public health services to numerous private and third sector companies and charities.
This effectively creates Integrated Care Providers as a very large pool of public money to be siphoned out by both the private “health support services” companies, and by private and third sector companies providing clinical front line services, public health and behaviour change schemes. With the added extraction of profits by PRIVATE FINANCIAL COMPANIES, through the ruse of financing NHS Integrated Care Provider Trust services via Social Impact Bonds. These pay out profits to the private equity investors if the schemes they fund achieve the required population health outcomes.
The new NHS Primary Legislation is being talked up by the Guardian as being about “scrapping laws driving privatisation of the NHS”. It is no such thing.
It is about enabling the introduction of Accountable care Organisations – now renamed as Integrated Care Providers. As trailed in last month’s House of Commons Health and Social Care Select Committee – MPs, technocrats and Secretary of State in NHS Long Term Plan Love In
A couple of weeks ago Polly Toynbee had a cheerleading Comment is Free article in the Guardian, clearly preparing the ground for people to think this upcoming primary legislation was going to be hunky dory. We rebutted this, here: Competition is unwelcome in the NHS – but “collaboration” that strips hospital services from whole areas and increases health inequalities is no solution
This proposed new NHS legislation is rubbish for all the same reasons Polly Toynbee’s Guardian article was rubbish – and then some.
Now reading the NHS England/NHS Improvement paper about the primary legislation, it is clear that it does exactly what Polly Toynbee was cheerleading for in her sorry Comment Is Free article that we rebutted.
The NHS England/NHS Improvement paper says
“We are … proposing a number of changes to both the C[ompetition and] M[arket] A[uthority]’s and NHS Improvement’s (Monitor) roles in respect of competition. Specifically, we propose removing the CMA’s function to review mergers involving NHS foundation trusts, removing NHS Improvement’s competition requirements and removing the need for NHS Improvement to refer contested licence conditions or National Tariff provisions to the CMA.”
To make sure NHS Improvement surrenders these functions, Simon Stevens has shoved aside the NHS Improvement chair, Ian Dalton, and taken on the position of Chief Exec of NHS Improvement as well as his existing position as Chief Exec of NHS England.
Increased use of personal health budgets – spun as increasing “patient choice”
The paper says despite the absence of competition resulting from those measures – and from Integrated Care Providers, which are to provide a whole range of health services for their area – patient choice would be “strengthened” through the roll out of personal health budgets.
Funny that, since the Royal College of Nursing has warned that they could be used to justify making cuts to community nursing. And the Nuffield Trust has suggested that personal health budgets would require some NHS services to be scrapped and this would reduce patient choice.
Personal Health Budgets are a backdoor form of privatisation. And they are already being gamed by NHS Commissioners to deny patients care they need and are entitled to.
Cutting hospital services in favour of providing “care in the community” – a key aspect of Integrated Care Systems – is accompanied by an increase in patients’ use of personal health care budgets.
They are paid for by Clinical Commissioning Groups out of their Continuing Health Care pot of money. The patients use this budget to buy in their own continuing healthcare.
This budget is determined by a Multidisciplinary Team that assesses the continuing healthcare needs of patients being cared for in the community, and work out the amount of personal healthcare budget they’re entitled to. And then their assessment goes to the Clinical Commissioning Groups, so they can pay the patient the personal healthcare money.
But barrister David Lock has found that Clinical Commissioning Groups are trying to get Multidisciplinary Teams to change/downgrade their assessment of patients’ Continuing Health Care needs and entitlements. And this is unlawful.
Flexible payment models – local prices for local health services
A further aspect of the legislation is to
“provide more flexibility in developing new payment models”.
The new flexible payment models seem to be about ending national tariffs/pricing and resorting to local prices for local NHS services. In other words the total fragmentation of the NHS. The NHS England/NHS Improvement paper proposes,
“once integrated care systems (ICSs) are fully developed, removing the current ability for providers to seek NHS Improvement’s agreement for unilateral local modifications to national tariff prices, so that the onus is on providers and commissioners to agree any local variations to national prices.”
Integrated Care Provider contracts won’t have to be put out to competitive tender
Another key aspect of the proposed primary legislation is to revoke regulations under section 75 of the Health and Social Care Act 2012 and repeal the powers in primary legislation under which they are made. This means Integrated Care provider contracts will not have to be put out to competitive tender. Potentially, this reduces the chance for private companies to get them.
However this needs to be take with a very large pinch of salt.
The Integrated Care Provider contract allows for the possibility that it will be held by a private company or other non-NHS organisation. So does secondary legislation introduced by the government on 13th February. And so do the Integrated Care Provider Contract directions for primary care services, that seem to say that ANYONE can enter an Integrated Care Provider contract to provide GP services.
New NHS Integrated Care Trusts
As well as repealing s75 of the Health and Social Care Act, the new proposed NHS primary legislation also states – as people with their ears to the ground have been predicting – that
“the Secretary of State should be given clear powers to establish new NHS trusts for the purposes of providing integrated care.”
“Taken together with the procurement changes we propose, this would support the expectation in the NHS Long Term Plan, and the Health and Social Care Select Committee’s recommendation, that the Integrated Care Provider (ICP) contract should be held by public statutory providers.”
In other words, an Integrated Care Provider could be a new NHS Trust.
We are guessing that this is what the Health Secretary Matt Hancock was talking about in the 28 January House of Commons Health and Social Care Committee meeting, when he said that they have come up for a way for GPs (which he calls private providers) to “bid in” for an Integrated Care Provider contract through an overarching NHS body that would be a public body. [17.20.28-17.20.48 on the Parliament TV video]
And Simon Stevens agreed that there would be an option for GP and community health services to be integrated in an NHS body without going through the current procurement process. [17.21.24 – 17.21.35 on the Parliament TV video]
But in response to Paul William’s question [17.16, Parliament TV video]
“Will there still be a role for non-NHS bodies in delivering NHS care?”
Simon Stevens confirmed that,
“There are ways of doing that that aren’t the inflexible periodical transactional procurement processes that currently operate through the system.”
This seems to directly contradict Appcock’s claim of “no NHS privatisation on my watch”, by affirming that non-NHS bodies could provide NHS services without going through the current competitive tendering and procurement process.
Hollow claims that Integrated Care Providers would be an NHS body
Hancock’s and Stevens’ assurances sound even more disingenuous when you consider that – as already mentioned – the Integrated Care Provider contract allows for the possibility that it’s held by a private company or other type of non- NHS organisation.
And then there is Statutory Instrument 2019 No. 248 – introduced by the government on 13th February to make regulatory changes so that primary care and other NHS services can be commissioned in one contract. Why didn’t the Department of Health include these proposed amendments in the proposed new NHS primary legislation? Rather than sneaking them in through a Statutory Instrument that bypasses MPs’ scrutiny and discussion. What exactly is the Department of Health trying to hide?
Could the reason be that the Explanatory Memorandum for Statutory Instrument 2019 No 248 says (6.20) that it’s possible for joint ventures to hold Integrated Care Provider contracts, as well as “more conventional provider models”?
The Explanatory Memorandum also says that the Statutory Instrument amends the Medical Performers List regulations to allow the addition of Medical Practitioners who are contractors under Alternative Provider of Medical Services or Integrated Care Provider contracts.
The significance of this is revealed in the Integrated Care Provider Contract directions for primary care services, which seem to mean ANYONE can enter an Integrated Care Provider contract to provide GP services.
These directions are based on directions for Alternative Provider of Medical Services (APMS) contracts, which were introduced by the New Labour government in 2004 to open up primary care to ‘new providers’. Alternative Provider of Medical Services contracts were then used to procure the ill-fated Darzi clinics that aimed to to take key aspects of secondary care – eg diagnostics, day surgery and management of chronic illnesses – out of NHS hospitals.
Darzi recommended new “GP-led health centres”, which would be run by “for-profit” providers. In their book The Plot Against the NHS, Colin Leys and Stewart Player write (p 45),
“What was really in prospect was corporate control of both primary care and a large part of existing NHS secondary care…”
A 2009 GP Magazine article said:
“APMS contracts are the private sector’s gateway to providing primary health care to NHS patients.”
What goes around, comes around – in even worse shape than before. The Integrated Care Provider Contract Directions explicitly OMIT the Alternative Provider of Medical Services directions that list those who are ineligible to hold an APMS contract, and that require NHS England to make sure that no one who is ineligible to hold an APMS contract, enters into one.
Those directions are now replaced by an Integrated Care Provider direction that says:
“Under the ICP arrangements, primary medical services would be provided as part of the wider contract. As such, it would not be appropriate to apply preconditions appropriate to individual performers of primary medical services.”
Are we right to read that as meaning NO ONE is ineligible to enter an ICP contract to provide primary care services? Any private company can apply?
Even if Integrated Care Providers WERE statutory NHS organisations, the type of healthcare they would provide is not fit for the public and requires increased NHS privatisation
We knew it was likely that legislation might be introduced to put Integrated Care Providers on a statutory footing, with the contract held by a public NHS organisation. This is what we said outside the Royal Courts of Justice at the rally before our Court of Appeal hearing:
“It seems clear from recent statements by the Health Secretary Matt Hancock, that the government wants Parliament to legislate to introduce the Integrated Care Provider contract.
“It is vital that if this happens, the Parliamentary opposition stops this in its tracks.
“Because even if the government were to introduce legislation that could possibly rule that only NHS organisations could hold Accountable Care Organisation/Integrated Care Provider contracts, it would still be a rotten contract that aimed to cut costs and ‘manage demand’ for NHS care.
“Accountable Care is not the kind of NHS that we need. We need an NHS where doctors and patients decide together on treatments face to face, based on clinical needs and patients’ values – not according to digital algorithms and financial considerations.
“Accountable Care models are a cash cow for global digital technology and life sciences companies. They are nothing to do with social solidarity for the ill and infirm, which is what our NHS is and needs to remain as.”
And as a lead provider for a very dodgy neoliberal model of health care, an Integrated Care Provider will subcontract many services to non- NHS organisations – whether private companies or social enterprises. This model relies on such privatisation.
And Integrated Care Providers and Systems will rely on the likes of Optum, Centene and Cerner to set up and run the “support services” that these Medicare/Medicaid copycats require in order to operate.
For us the issue has always been that Accountable /Integrated Care is about replacing the NHS with a copy of the USA’s Medicare/Medicaid system that only provides limited publicly-funded healthcare for patients who are too poor and/or ill to get private health insurance. And this primary legislation is entirely designed to enable the completion of this sorry project.
But don’t take my word for it – here is the NHS England/NHS Improvement paper .
Updated 3 March 2019 to include information about statements by Matt Hancock and Simon Stevens to the 28.1.19 Health and SOcial Care Select Committee; Simon Stevens’ putsch of Ian Dalton from the position of Chair of NHS Improvement; and the section headed “Hollow claims that Integrated Care Providers would be an NHS body”