NHS England’s Long Term Plan legislation proposals are rubbish – here’s our full response to the “engagement”

NHS England has invited comments on proposals for new NHS legislation that will fragment the NHS into local Accountable Care Organisations – now rebranded as Integrated Care Providers

This ambition is the focus of their NHS Long Term Plan.

We have responded to their engagement by telling them we do not agree with their proposed changes to primary legislation. Here is our full response.

999 Call for the NHS Response to NHS England’s engagement on Long Term Plan legislation

Should the law be changed to prioritise integration and collaboration in the NHS through the changes we recommend?

The law should be changed to restore the duty of the Sec of State to provide or secure the provision of a comprehensive, universal NHS that is free at the point of clinical need and fully publicly funded, owned, managed and provided by directly employed NHS staff. These principles should also be extended to the provision of social care.

The NHS must be run by and accountable to local and national government and devoid of all privatisation, whether privatised administration, healthcare provision, support services or capital ownership. The NHS is concerned with health and social care provision and should not be subject to market forces either internal or external.

This principle extends to medical innovation: the process of devising and implementing strategies and health interventions that improve health outcomes at the community level, which may or may not include using health technologies like diagnostics, medicines, vaccines and medical devices, (often referred to as health commodities).

We do not agree with your proposed changes to primary legislation. They will not lead to a sustainable, rationally and equitably planned and provided comprehensive, universal NHS and social care service. They will merely patch a tattered legislative fabric and impose cost-cutting American models of accountable care on our NHS, fragmenting it into local health services.

1 Promoting collaboration

This includes the following proposals:
a. Remove the Competition and Markets Authority (CMA) function to review mergers involving NHS foundation trusts
b. Remove NHS Improvement’s competition powers and its general duty to prevent anti-competitive behaviour
Remove the need for NHS Improvement to refer contested licence conditions or National Tariff provisions to the CMA

a) Competition is unwelcome in the NHS – but “collaboration” that strips hospital services from whole areas and increases health inequalities is no solution.

With regard to the recent ruling that the two struggling Dorset hospitals in Bournemouth and Poole can merge to share services, Dorset Clinical Commissioning Group has been put in a position where running a full-service hospital in Bournemouth and a full-service hospital in Poole (half an hour to the west) is beyond its means. With the result that Poole Hospital is now threatened with shutting down its Maternity, Paediatric, A&E and Trauma services.

That could be dressed up as a victory over the “competition dogmatists” in the Competition and Markets Authority who wanted Bournemouth and Poole Hospitals to compete with each other. But it doesn’t look like any kind of victory to the thousands of Dorset residents who have crowdfunded a judicial review against losing vital A&E and other key services from Poole Hospital so that they can be centralised at the more distant, less accessible Bournemouth hospital.

Dorset County Council’s Health Scrutiny Committee, supported by the Borough of Poole Health and Social Care Overview and Scrutiny Committee, has referred the proposal to the Secretary of State for Health on the grounds that it is not fit for the public.

The merger of Ipswich and Colchester hospitals is likely to increase health inequalities. According to Support the NHS Colchester, there’ll be an A&E as well as maternity at each hospital, but other units will be shared out. People will have to travel from quite rural areas, with little affordable public transport. There’s no plan in place to deal with patient – or staff – access.

b) and c) We think NHS Improvement should be abolished.

2 Getting better value for the NHS – Do you agree with our proposals to free up procurement rules including revoking section 75 of the Health and Social Care Act 2012 and giving NHS commissioners more freedom to determine when a procurement process is needed, subject to a new best value test?

We think the Health and Social Care Act 2012 should be repealed in its entirety, along with all other NHS marketising and privatising legislation and regulation as identified in a Consequential Provisions Bill to accompany the NHS Reinstatement Bill. This is the primary legislation that needs to be enacted. We do not think contracts and their procurement should be the basis of providing NHS services.

3 Increasing the flexibility of national payment systems

Do you agree with our proposals to increase the flexibility of the national NHS payments system? This includes the following proposals:
a. Remove the power to apply to NHS Improvement to make local modifications to tariff prices, once ICSs are fully developed
b. Enable the national tariff to include prices for ‘section 7A’ public health services
c. Enable national prices to be set as a formula rather than a fixed value, so prices can reflect local factors
d. Enable national prices to be applied only in specified circumstances
e. Enable selected adjustments to tariff provisions to be made within a tariff period (subject to consultation)

We think NHS Improvement should be abolished, along with NHS England and Clinical Commissioning Groups and the purchaser-provider split. This would enable a rational planning and payment process to be set up, whereby the regional and local responsible bodies – Special Health Authorities, Health Boards or Community Health Councils – plan and cost the provision of health and social care on the basis of local needs and within the global regional/local sum provided by the Secretary of State/Treasury on the basis of Parliamentary decisions about the budget.

The consensus among NHS providers, as stated at the House Of Lords Committee on NHS sustainability is that a yearly 4% NHS funding increase is needed to keep pace with population growth and cost inflation in the NHS.

However, when you start looking at the reasons for NHS cost inflation it seems that this may be largely down to the costs of new pharmaceuticals and digital technology needed to drive the profiteering corporate transformation to Healthcare 2.0. Our proposal to bring the development of drugs and medical technologies into public ownership will save a lot of money.

In addition, a big source of continuing financial pressure is the sickness-creating effects of austerity, unregulated workplaces, growing inequalities and environmental degradation. It is imperative that adequate focus is put on policies that tackle the social economic and environmental determinants of diseases such as type 2 diabetes, cardio-vascular disease, asthma and some cancers, and on providing living environments that promote health, support healthy lifestyles and reduce health inequity.

4 Integrating care provision

Do you agree that it should be possible to establish new NHS trusts to deliver integrated care?

We don’t agree with the model of “integrated care” that the current government and its NHS quangos are promoting. This is essentially cost-cutting USA accountable care, rebranded as Integrated Care Providers.

The proposed NHS Integrated Care Provider Trusts would turn the NHS into a set of local private/public partnerships. NHS England is contracting “health support services” providers such as Optum to set up the data and analytics systems required by Accountable Care Organisations aka Integrated Care Providers. This is one type of public/private partnership, which we reject. And as lead provider of a whole range of health and social care services for its area, the NHS Integrated Care Provider Trusts would subcontract many front line NHS, social care and public health services to numerous private and third sector companies and charities. This is a second form of public/private partnership.

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.

5 Managing the NHS’s resources better

Do you agree that there should be targeted powers to direct mergers or acquisitions involving NHS foundation trusts in specific circumstances where there is clear patient benefit?

Do you agree that it should be possible to set annual capital spending limits for NHS foundation trusts?

We think NHS Foundation Trusts should be abolished. We don’t want hospital mergers or acquisitions. Problems are created by so-called ‘economies of scale’ where, in an attempt to emulate industry, hospitals and common services are merged into larger entities regardless of the nature of the variety of demand. Individual and local knowledge are lost and problems are dealt with according to protocols and pathways, not what is best for the patient. This has to change. The system must be designed around what the patient needs. Professionals must be given the time to care, rather than ticking boxes.

We want a more rational planning system carried out by the regional and local responsible bodies – Special Health Authorities, Health Boards or Community Health Councils. This would include planning and allocation of capital spending for hospitals and other NHS facilities, including primary and community care.

6 Every part of the NHS working together

Do you agree that CCGs and NHS providers be able to create joint decision-making committees to support integrated care systems (ICSs)?

We don’t agree with the purchaser/provider split in the first place, so trying to legislate for joint commissioner/provider decision-making committees is beside the point.

The NHS Reinstatement Bill should be enacted. It will abolish Clinical Commissioning Groups, once the Secretary of State has approved draft schemes setting up local Health Boards. It reverts all their property, rights and liabilities to the Secretary of State.

The NHS Reinstatement Bill will also abolish NHS Trusts and NHS Foundation Trusts, with everything that had belonged to them reverting to the Secretary of State.

These measures abolish competition and the purchaser/provider split and replace them with a more rational planning and decision making process carried out by the regional and local responsible bodies – Special Health Authorities, Health Boards or Community Health Councils.

We don’t agree with Integrated Care Systems. The Accountable/Integrated Care model they are designed to deliver are – like the Lansley “catastrophe” they are intended to replace – built on NHS cuts proposals that the global management consultancy company McKinsey produced for the New Labour government after bankers crashed the global economy.

So in our strongly held view, legislating to support Integrated Care Systems is beside the point.

These are some key features of the new cuts-driven “collaborative” model of the NHS, which we strongly object to:

• Cuts and centralisation of District General Hospitals – including the downgrade or closure of at least 23 full blue light A&E departments that we’re aware of.
• Bed closures in many community hospitals.
• Moving hospital services into new primary care networks serving 30K-50K patients that each shares a “locality hub” serving up to around 180k patients – a massive and unevidenced change to primary and community health services.
• Restricting patients’ access to GPs – who will mostly only see high cost patients with complex conditions. New grades of less qualified staff will see everyone else.
• Pushing much of the work of health and social care onto patients themselves, their families, friends and voluntary sector organisations.
• Large scale behaviour change schemes targeted at patients suffering from or deemed to be at risk of non-communicable illnesses (eg obesity, diabetes, anxiety, depression, heart and respiratory problems) – regardless that their causes are largely social, economic and environmental injustice and deregulated corporations.
• Remote digital monitoring of people’s bodily functions through wearable technology – with pretty horrendous privacy and civil liberties implications (discussed by Shoshana Zuboff in her Surveillance Capitalism book).

Do you agree that the nurse and secondary care doctor on CCG governing bodies be able to come from local providers?

They already do in Calderdale Clinical Commissioning Group Governing Body, so what is this about?

Do you agree that there should be greater flexibility for CCGs and NHS providers to make joint appointments?

As already mentioned, we think Clinical Commissioning Groups and NHS Trusts and Foundation Trusts should be abolished by passing the NHS Reinstatement Bill. So this proposal is irrelevant.

7 Shared responsibility for the NHS

Do you agree that NHS commissioners and providers should have a shared duty to promote the ‘triple aim’ of better health for everyone, better care for all patients and to use NHS resources efficiently?

As already mentioned, we think Clinical Commissioning Groups and NHS Trusts and Foundation Trusts should be abolished by passing the NHS Reinstatement Bill. The duty to deliver the aims of the NHS as a comprehensive, universal health service that is that is free at the point of clinical need and fully publicly funded, owned, managed and provided by directly employed NHS and social care staff, should be restored to the Secretary of State and delegated as appropriate to the regional and local responsible bodies – whether Special Health Authorities, Health Boards or Community Health Councils.

In terms of which aims the NHS should have the duty to promote, we think these are most important:

• It should make sure that patients are able to freely discuss and decide with clinicians which treatments they are happy to receive.
• It should make sure that it is a good employer that looks after the emotional and professional needs of its staff, in order that they can provide the standard of compassionate care that they trained hard to be able to deliver.
• This requires adequate workforce planning and training.
• The excellent standards of compassionate care available in the best NHS hospitals and other facilities should be shared everywhere.
• The Sec of State for Health and Social Care should have a duty to make sure in Cabinet that a ‘health in all policies’ approach is adopted across the whole of national and local government. This requires legislation to effectively promote environmental, social and economic justice, since these are strong determinants of good health. These policies should be properly funded.
• It should make a clear statement that ill health is strongly associated with poverty and deprivation, and people in such circumstances can’t afford to pay for a “healthy lifestyle.” If they could, they wouldn’t be ill. It should distance the NHS from the adoption of nudge and behaviour change schemes as appropriate means of improving public health.

8 Planning our services together

Do you agree that it should be easier for NHS England and CCGs to work together to commission care?

We think that NHS England and Clinical Commissioning Groups should be abolished by passing the NHS Reinstatement Bill.

Care should be planned and provided through 4 levels of NHS organisations as specified by the NHS Reinstatement Bill:

• The Secretary of State
• NHS England (a Special Health Authority – NOT the current quango, which the NHS Reinstatement Bill will abolish), Public Health England, and other Special Health Authorities as the Secretary of State finds necessary. Where other Special Health Authorities are set up, this must be accompanied by a statement explaining how bureaucracy will be reduced as a consequence of such an order.
• Local Health Boards (including local authority membership)
• Community Health Councils

Each organisation is responsible for making decisions that are appropriate to their level.

9 Joined-up national leadership

Which of these options to join up national leadership do you prefer?

a) combine NHS England and NHS Improvement

b) provide flexibility for NHS England and NHS Improvement to
work more closely together

c) neither of the above X

We think NHS England and NHS Improvement should be abolished.

Do you agree that the Secretary of State should have power to transfer, or require delegation of, ALB functions to other ALBs, and create new functions of ALBs, with appropriate safeguards

No. The NHS should not be administered through Arms Length Bodies.