If you are worried about the way the 2012 Health and Social Care Act effectively removed the Secretary of State’s duty to provide the NHS for all of us, sorry, but things have just got worse.
The West Yorkshire and Harrogate Integrated Care System Board Terms of Reference were presented to the Board on Tuesday 3rd September. The Board’s Terms of Reference further weaken democratic accountability for the NHS and look more like a spivs’ charter than anything else.
At the West Yorkshire and Harrogate Joint Health Scrutiny Meeting on 10 September, Rosemary Hedges from Calderdale and Kirklees 999 Call for the NHS asked questions about this. (More below in section ‘Problems with the Integrated Care System Board Terms of Reference’ The meeting ignored her questions.
Chronically underfunded plan with key aspects influenced by Optum – a profiteering American company
Jenny Shepherd, a member of Calderdale and Kirklees 999 Call for the NHS, spoke of her concern that, by stealth, a private profit-making American company, Optum, is directing a key aspect of the Integrated Care System 5 Year Plan – the new priority of improving population health.
Dr John Puntis, from Leeds Keep Our NHS Public, asked why important elements are missing from the draft five year strategy. Particularly the fact that extra funding promised by Teresa May last summer will be swallowed up by paying off NHS organisations’ “deficits” that have built up over years of under-funding.
The result is that the planning process for NHS, social care and public health services in West Yorkshire and Harrogate – which the Board is somehow now responsible for – is in no way rational or fit for purpose.
The Board’s draft 5 Year Strategy 2019-24 has to be submitted to NHS England by 27th September. It is meant to detail how the Integrated Care System is going to carry out the NHS Long Term Plan.
Here are the NHS defenders’ deputation statements.
Problems with the Integrated Care System Board Terms of Reference
Rosemary Hedges’ deputation questions the problematic Terms of Reference of the Integrated Care System Board, which is responsible for the 5 Year Operational Plan 2019-24.
There’s a basic contradiction between statutory powers to be delegated to it by the NHS England and NHS Improvement quangos, and the Board’s total lack of any statutory status.
The Integrated Care System is a non-statutory non-organisation. The Terms of Reference say the Board has no formal delegated powers from the organisations in the Integrated Care System: it
will make joint decisions on a range of matters which do not impact on the statutory responsibilities of individual organisations and have not been delegated formally to a collaborative forum.”
These seem to be substantial limitations on its joint decision-making power. But the Terms of Reference also say the Integrated Care System leadership is going to carry out the NHS quangos’ regulatory and oversight functions. These functions were created in the 2012 Health and Social Care Act. So surely they must be statutory functions?
We would like the Joint Health Scrutiny Committee to find out how the Leadership in the Board of a non-statutory non-organisation can carry out statutory functions
So our next questions are:
How can you reconcile the Board’s planned exercise of the statutory NHS quangos’ oversight and regulatory functions with the documented limitations of its role and lack of statutory status?
And how can the statutory member organisations of the Integrated Care System be subject to the Board of a non statutory non organisation, exercising statutory functions delegated from statutory quangos?
3.1.v says this non-statutory non-organisation Board with no formal delegated powers from the statutory organisations in the Integrated Care System, has the power to control how its statutory members’ money is spent. It will:
“oversee financial resources of NHS partners within a shared financial framework for health across the constituent CCGs and NHS provider organisations; and to maximise the system-wide efficiencies necessary to manage within this share of the NHS budget”.
This is our public money and it is being disposed of in a way that seems decidedly dodgy if you are at all bothered about accountability and respect for statutory processes.
The Integrated Care System Board has apparently somehow usurped the financial, regulatory and oversight powers of the statutory NHS organisations at national and local levels.
It gets worse.
The heavy hand of Optum – profiteering American health support services company
3.1.vii shows the heavy hand of Optum – the profiteering American health support services company that is also a former employer of the NHS England boss, Simon Stevens.
That paragraph commits the non-statutory non-organisation Integrated Care System Board to making sure that the member NHS, social care and public health organisations operate what is clearly – if not explicitly – the Optum system of population health management in primary and community health services.
Our final question:
Is it right that a key aspect of the 5 year plan is based on the practices of an American health support services company?
This question was picked up in a deputation statement by Jenny Shepherd, also from Calderdale and Kirklees 999 Call for the NHS. Here it is:
The new priority in the draft 5 year Integrated Care System plan: Improving population health.
My deputation is about the new priority in the draft 5 year integrated care system plan: Improving population health.
My concern is that, by stealth, a private profit-making American company is directing a key aspect of the Integrated Care System 5 Year Plan.
On June 4th the Integrated Care System Board decided to:
“expand the existing prevention programme into a new improving population health programme”.
This decision immediately followed a 20 week population health management programme in Leeds, delivered by Optum and PwC and paid for by NHS England.
In the USA, Optum’s population health management system is central to the business model of “managed care” provided by the USA’s Accountable Care Organisations.
Research has found that commercialisation of health services, such as this, reduces patients’ access to professional health care and worsens population health.
But the 5 year plan spin is the opposite – that population health management incentivises Primary Care Networks to tackle health inequalities and preventable illness – and so cuts costly unplanned hospital attendance and admissions.
The incentive is that Primary Care Networks are being allowed to keep some of the contract money that they don’t spend on patients’ care. (The rest is shared with the NHS commissioners – so-called aligned incentives.)
Do you want the NHS to be run like a business where money comes before patients’ needs?
The February 2019 Leeds Population Health Management Newsletter shows that during the 20 week programme, Optum basically supplanted the statutory Leeds Clinical Commissioning Group and Leeds City Council commissioners by:
- redesigning care for the frail elderly and
- providing actuaries and population health analytics to the Leeds commissioners’ business intelligence team, to produce material to do with the business model for the redesigned frail elderly care model.
Let’s hope the West Yorkshire and Harrogate Joint Health Scrutiny Committee can get an explanation of what Optum’s done, because we don’t understand the business intelligence stuff.
It’s not just limited to Leeds.
The draft 5 year plan p28-29 states that the Integrated Care System Board will support “places” (jargon for Local Authority areas) with development in Population Health Management. Among other support, the Board will:
“share… the approach Leeds has taken to using a PHM approach to improve outcomes for those living with frailty.”
This is obviously a reference to Optum’s work.
My final point concerns the 5 Year Plan’s drive for innovation at the expense of evidence.
Of course, adding a population health management programme to the Integrated Care System’s 5 year plan depends on the availability of technology for a population health management tool.
On 25th June news emerged that NHS England had provided £4m for the Yorkshire and Humber Local Health and Health and Care Record Exemplar (LHCRE) to buy the necessary digital technology from Deloitte, Google and Synanetics (a North Yorkshire healthcare IT company).
The draft 5 year plan crows:
“how open we are to innovation and how the whole system can work together with organisations such as the Yorkshire and Harrogate Academic Health Science Network (AHSN), Leeds Academic Partnership and the health tech industry.”
The example given is population screening for atrial fibrillation – but a recent BMJ editorial states that this is not recommended by the National Screening Committee.
Too bad the Integrated Care System’s drive for innovation and working with the health tech industry overrides the drive for evidence.
This isn’t only in relation to population screening for atrial fibrillation. The prioritisation of population health management ignores research evidence that contradicts the claims made for it in the 5 year plan.
Integrated Care System Director denies Optum’s influence over 5 Year Plan
The Director, Ian Holmes, said that Optum and population health management are not synonymous. It is evolving differently in different places. Optum were not involved in drafting the population health management section of the 5 year strategy.
Update 13.12.2020 However, there are other ways Optum has been influencing Integrated Care Systems’ 5 Year Plan, without having a hand in drafting them.
In the Journal of Integrated Care, Optum’s Chief Medical Officer and the Dorset Clinical Commissioning Group’s Assistant Clinical Director give an account of the same 20 week Optum course on Population Health Management in Dorset that was also delivered to West Yorkshire and Harrogate Integrated Care System in Leeds. They say that in all four Integrated Care Systems where the course was held, it was based on
“…tak[ing] what integrated data was available and work[ing] with emerging P[rimary] C[are] N[twork]s to implement change in the management of a locally determined cohort of patients...
“…with the support of Optum and NHSE/I and NHS Digital, Dorset formed its own PHM data platform; The Our Dorset intelligent working programme (IWP) was established to support the ambitions of the NHS Long Term Plan and PHM programme in Dorset as part of the Digitally Transformed Dorset STP portfolio, to improve the way information is used to support service improvement, planning and development.
IWP and the Dorset Intelligence and Insight Service (DiiS) will deliver, seek to support the infrastructure and intelligence strands of PHM…The programme collects data currently from approximately 80% of practices and is set to deliver an updated data stream every 24 h for the Dorset ICS by the end of the year.
The Optum/Dorset Clinical Commissioning Group account of the 20 week Optum course adds,
Dorset’s [GP] practices…had never before shared data in this way. Clear information governance guidance was developed for them to feel secure in participating in the programme…undertaking this process deepened the relationships between analysts and PCNs in Dorset, with analysts becoming part of the clinical and management teams, sitting together to find the answers the clinicians asked of the data – a powerful triad. This has led to development and training opportunities to promote the role of the analysts within the system leading to the development of a training academy and has enabled PCNs to develop the infrastructure required for a mature PCN ( ref Maturity Matrix NHSE/I 2019).
We need to find out from West Yorkshire and Harrogate Integrated Care System whether there has been similar embedding of Optum systems and analysts in Primary Care Networks in our area. And whether the Optum Population Health Management course resulted in setting up the Integrated Care System’s own Population Health Management data platform, similar to the Our Dorset intelligent working programme.
Why are important elements missing from the draft five year strategy?
This was the theme of the deputation statement by Dr John Puntis, Keep Our NHS Public:
There is an acknowledgement in the draft 5 year strategy of the chronic underfunding of the NHS but not the fact that £20m from Mrs May, should it ever materialise, is wholly inadequate for making up the existing deficit.
The fact that the increased funding on offer will generally be absorbed in restoring financial balance is acknowledged, while at the same time it is implied that it will be possible to deliver the many uncosted and ambitious service developments set out in the long term plan.
Impressive targets are set for smoking reduction at the same time as the public health budget for smoking cessation services has been cut, and while poor oral health is rightly identified as a serious problem there is no commitment to water fluoridation, the single most effective intervention for preventing dental caries. At a time when prevention is being promoted as the solution to reducing demand on the health service, public health budgets are being severely cut.
The underfunding of social care is identified as a problem causing huge strain on the NHS, but while the financial problems of the care home sector are referenced, the instability that comes from a financial model encouraging hedge funds and private equity investors to extract massive profits is not mentioned. There is a crying need for long term care to be brought back into the public sector.
Clinical Commissioning Group mergers go against the localism promised with the Health &Social Care Act 2012 and distance decision makers further from communities without even the legally required consultation process having been followed.
No mention is made of the massive costs associated with marketisation and competition in health care, whereas an opportunity could be taken to highlight the huge waste of resources associated with this failed experiment – coupled with a call for the restoration of the NHS as a public service.
Austerity as a political choice is widely identified as a cause of ill health and premature death as well as stalling life expectancy and yet is not mentioned.
The Integrated Care System Board members pretty much ignored the points raised by the public
Cllr Betty Rhodes (Wakefield) picked up the point that extra funding isn’t making up for what austerity took out – but extra demands on the NHS need meeting. The Integrated Care System Board members ignored her comment.
Cllr Colin Hutchinson (Calderdale) asked for clarification of the role of Optum and PwC in Leeds population health management. The Integrated Care System Director Ian Holmes denied that Optum were involved in drafting the population health management section of the 5 year strategy. Which didn’t exactly answer Cllr Hutchinson’s question.