American health insurance and digital technology companies are poised to take up near-monopoly positions running the NHS, once its fragmentation into up to 42 so-called Integrated Care Systems is cemented by proposed legislation that would take effect from April 2022.
That is, if Simon Stevens – former CEO of the Medicare business of the world’s largest health insurance company United Health (2020 revenue, $251.08 bn) and President of its Global Health division – has his way.
The quango NHSEngland/Improvement, headed up Simon Stevens, recently advocated legislation to turn Integrated Care Systems into statutory corporate NHS bodies. This would complete their takeover of the NHS, which has been going on for the last five years.
Cementing the American insurance and digital data companies’ dominance of key NHS planning and commissioning roles would be achieved by the abolition of NHS Clinical Commissioning Groups, with their strategic functions absorbed into the Integrated Care Systems. (para 2.64, Integrating Care Next Steps)
Actuarial processes are already being introduced into NHS commissioning by American health insurance and digital technology companies eager to pursue the profits they will gain from access to the unique digitised treasure of over 70 years worth of a whole country’s personal medical data.
Our confidential medical data are already being widely shared with these companies, as they embed methods of controlling spending by identifying individual patient costs to the NHS.
The public has until 8th January 2021 to tell the quango what we think of the proposed legislation. CK999 will soon be blogging our response as well as sending it to NHS England/Improvement. [Update: Here’s the link.]
If and when you are ready to do this, here is how to respond to the proposals in the Integrating Care Next Steps document:
- Via this online survey: www.engage.england.nhs.uk/survey/building-a-strong-integrated-care-system
- Email to firstname.lastname@example.org or snail mail to NHS England, PO Box 16738, Redditch, B97 9PT.
Why should we care?
The proposed legislation would seal the degradation of the NHS from a comprehensive, universal public service that’s based on meeting people’s medical needs (not on our ability to pay), into a state-funded business where access to health care is driven by actuarial considerations.
You can see where this is going – this so-called ‘managed care’ imported from the USA’s Medicare system is a way of cherry picking patients whose treatment offers the ‘best value for money’, and denying the rest of us access to treatment – or making it conditional on participation in behaviour change schemes, largely run by social enterprises or private companies.
What are Clinical Commissioning Groups? Why do they exist?
To put it simply, for several decades now successive governments have required the NHS to act as a business not a public service. This process escalated this century, first under the New Labour government (which Simon Stevens was an advisor to before leaving for United Health) and then under the ConDem and Tory governments.
Back in Thatcher’s day, hospital cleaning was contracted out to private companies. Hospital infections almost immediately became a problem as the cleaning wasn’t very good – profit making trumped quality of service. In 1990 the NHS and Community Care Act split the NHS into an internal market of ‘service purchasers’ and ‘service providers’. This required hospitals and GPs to compete with each other for patients, with the incentive of receiving more funding if successful.
Over the years governments opened up the NHS ‘market’ to include private companies and social enterprises. More and more bits of the NHS have been privatised, particularly since 2012, when the ConDem government legislated to create 211 Clinical Commissioning Groups. They are responsible for buying pretty much all local NHS services in a marketplace open to NHS providers, private and social businesses.
And it wasn’t just clinical services that were privatised. Commissioning itself has been, too.
How did American health insurance and ‘managed care’ companies get their foot so far in the NHS door?
From the start, US health insurers and UK outsourcing companies were hungrily eyeing the spoils to be gained from privatisation of NHS commissioning – and actively lobbying the Health Secretary Andrew Lansley.
His Diaries record that three UnitedHealth representatives attended a September 2010 meeting he gave to the Commissioning Services Industry Group. (Other Group members included the CEO of the UK outsourcing firm, Tribal, who had recently said that Lansley’s plans ‘could amount to the denationalisation of health care services in England’, which ‘could result in the biggest transfer of employment out of the public sector’ since Thatcher’s reforms. There were also representatives of the UK arm of US health insurance giant, Aetna and European MD of rival US insurer, Humana, both of which were seeking to provide NHS commissioning services.)
Seeking to exploit the opportunities presented by the Government’s upcoming NHS ‘reforms’, six months later United Health refocussed its UK business to concentrate solely on commissioning support. The American health insurer said it believed it could play a key role in helping the NHS make £20bn in efficiency savings, through expanding its commissioning support in areas such as data analytics, demand management and medicines management. It sold off its network of GP surgeries to The Practice Group – later acquired by Centene, a US “managed care” corporation that acts as an intermediary between government and public health care services.
By November 2011 United Health – operating under the name Optum – was already working with a number of Primary Care Trusts and GP consortia, including pathfinders in Hounslow who signed a deal with the firm to run a major crackdown on GP referrals.
Nine years later, the American health insurer’s former President has been ensconced for six years as CEO of NHS England (its real name is the NHS Commissioning Board) and is now proposing to legislate to abolish NHS commissioners. This will clear the space for United Health/Optum and other companies.
Steps towards the privatisation of NHS commissioning, 2012- 2020
Since 2012, the steps towards the privatisation (and Americanisation) of NHS commissioning have gone like this:
Put GPs in charge of buying local NHS services, by settting up 211 Clinical Commissioning Groups.
Oh! But GPs don’t have commissioning experience. So set up Commissioning Support Units (mostly done by the Big4 Accountancy Companies – eg KPMG Leeds office seconded Pete Thomas to work as Finance Lead for the new NHS West Yorkshire Commissioning Support Unit). That way the GPs can pay the Commissioning Support Units to do the commissioning for them.
Appoint Simon Stevens – hotfoot from American health insurer United Health – as head of the NHS Commissioning Board. (Make sure not to call it that, call it NHS England instead which conveniently hides its role.)
Simon Stevens sets up the secretive Commissioning Support Industry Group, chaired and funded by United Health. (Looks like the successor to the Commissioning Services Industry Group that lobbied Lansley in 2010).
The Commissioning Support Industry Group draws up an approved suppliers list (Lead Providers Framework) for privatisation of Commissioning Support (worth £3-£5Bn – a very big privatisation). Surprise surprise United Health is the lead provider for nearly all the Commissioning Support Units.
NHS England decides to close down the Yorkshire and Humber Commissioning Support Unit on 31st March 2016. 23 Yorkshire and Humberside Clinical Commissioning Groups contract the eMBED private health consortium (hosted by Kier Business Services Ltd) to provide commissioning support services for four years with the option to extend for a fifth year. The contract is worth approximately £18m/year. The eMED consortium consists of health information business Dr Foster, advisory firm Mouchel Consulting, accountancy firm BDO and consultancy Engine. (Dr Foster is a joint venture with the Department of Health, as a result of a £12m secret deal criticised by the National Audit Office in a 2006 report.) It seems from this Huddersfield Examiner story that this year ‘local health chiefs’ decided to move the eMBED Health Consortium services back in house, TUPEing 150 staff to new NHS employers, including Calderdale and Huddersfield NHS Foundation Trust’s The Health Informatics Service. (THIS is whole other (but related) story, coming soon. )
Two years later, in 2018, the NHS Commissioning Board aka NHS England replaces the Commissioning Support Lead Providers Framework with the Health Systems Support Framework. The new Framework has the explicit function of providing the “support services” needed to get Integrated Care Systems up and running. Specifically: “digitisation of services and the use of data to drive proactive population health management approaches across Primary Care Networks (PCNs) and integrated provider teams.” The accreditation of companies through the Health Systems Support Framework amounts to the privatisation and Americanisation of NHS Commissioning: Commissioners are required to pay private companies to do the work for them of setting up and using a commercial insurance-based model within the NHS shell of Integrated Care Systems.
Last September, NHS England added an “Innovation Greenhouse” lot to the Health Systems Support Framework, according to documents issued to suppliers. (Info from the NHS Procurement website.) This was in order to provide faster routes for Integrated Care Systems to buy “tried and tested innovations for patients, populations and NHS staff”.
This September (2020) NHS England issued a contract notice inviting bids to a new £30m Health Systems Support Framework lot: Workforce Deployment Solutions. This is for innovative software package and information systems that “address a health and/or social care challenge within the eRostering, job planning and temporary staffing software solutions service description…workforce and HR solutions which can help to deliver the NHS Long Term Plan and NHS People Plan.”
This new Workforce Deployment Solutions lot is directly related to the goal of handing Integrated Care Systems more responsibility for workforce planning, as the NHS People Plan stated.
Two years after the Health Systems Support Framework accredited companies to provide “commissioning support” to set up Integrated Care Systems, Simon Stevens advocates legislation to abolish Clinical Commissioning Groups and hand their strategic commissioning functions to statutory Integrated Care Systems (formerly known as Accountable Care Organisations).
Barcoding patients to track their costs to the NHS
Funny that the Health Systems Support Framework doesn’t seem to make any prominent mention of Patient Level Information Costing Systems. These require hospitals, mental health, community and ambulance services to cost the care individual patients receive, by combining healthcare activity information with financial information in one place. In other words, each resource that the patient uses is recorded and costed – eg staff time (in ward minutes), drugs and diagnostic tests etc. Patient Level Information Costing Systems requires finance and clinical teams to work together to embed the use of individual patient costing as business as usual.
NHSE/I’s Approved Costing Guidance 2020/21 tells providers how what integrated information they need to collect in order to provide Patient Level Information Costing Systems data to their business intelligence dashboards, for “effective local reporting, with outputs that can be used as part of the decision-making process at regular intervals.”
What effect is all this going to have on clinicians’ duty of care to their patients?
Population health management: integrating personal medical data to identify cohorts of high-cost patients
The other key aspect of this actuarial integrated data collection is Population Health Management, which involves commissioners identifying cohorts of high-cost patients. Optum already uses this “risk stratification” system to assess patients for America’s privatised insurance-led system. In 2019 NHSE paid Optum to go round the country running 20 week Population Health Management courses for 4 Integrated Care Systems in Leeds, Dorset, Berkshire and Cumbria & S Lancashire.
In Dorset the course involved Optum
“tak[ing] what integrated data was available and work[ing] with emerging PCNs to implement change in the management of a locally determined cohort of patients.”
In Leeds, 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.
Risk stratification, based on linked personal medical data from hospitals, GPs and other providers, divides NHS patients into high, medium and low risk groups which correlate with the cost of the treatments they receive.
Here’s an account of the 20 week Optum Course for Dorset by Optum’s Chief Medical Officer, Clinical Delivery, Dr Martin McShane and Dr Karen Kirkham, Dorset Clinical Commissioning Group Assistant Clinical Chair, Dorset Integrated Care System Clinical Lead and Senior Medical Adviser to NHS England’s Primary Care Provider Transformation Team. The Optum course was about how linking and analysing data is used to:
“influence the behaviour of professionals delivering care and individuals managing their own lives”
And here is Dr Martin McShane on the Cumbria and S Lancs version of the Optum Population Health Management course.
A toxic commissioning soup designed to cut our access to NHS treatments.
Opportunities for corruption
The government’s response to the Covid19 pandemic has followed the Disaster Capitalism/Shock Doctrine template, with the corrupt and secretive handing out of £bns of public money to companies, often with financial and personal connections with the Conservative Party. This has been made possible by the emergency suspension of requirements to publicise contract opportunities so that companies are able to bid freely for them.
A similar process could easily result from the proposals in the Integrating Care Next Steps document to abolish the requirement for competitive tendering of contracts. Collaboration is a very nice buzz word, liberally scattered throughout NHS England/Improvement’s Integrating Care Next Steps document.
But if you’re going to be handing out contracts to private companies (and we don’t think they’ve any place in the NHS), doing this in the absence of competitive tendering is wide open to abuse, as we’ve seen with the Covid19 contracts.
Exempting private companies with their eyes on NHS contracts from competition rules and regulation is just what this proposed legislation would do. It would ditch the Section75 competitive tendering requirement of the 2012 Health and Social Care Act and remove NHS services from the scope of the public contracts regulations 2015. (Para 2.61, Integrating Care Next Steps)
This could cement the position of Optum as a near-monopoly provider of the strategic commissioning functions of Integrated Care Systems. In other words, handing it the power of deciding what NHS and social services should be provided, when and how and to whom,
This doesn’t bode well for the future of privatised commissioning in statutory Integrated Care Systems.
And just in case accrediting Optum and other companies on the Health Services Support Framework might not be enough to enable them to take over strategic commissioning of NHS Integrated Care Systems, over the last few years NHS England has “invited” scores of Clinical Commissioning Groups to work with Optum and PWC to change their commissioning processes in line with USA health insurers’ and accountable care organisations’ methods.
If Simon Stevens’ proposed legislation is enacted by Parliament, the privatisation of NHS Commissioning will be done and dusted and put in the hands of US companies.
However Boris Johnson and his secretive Downing Street NHS taskforce might have other ideas Apparently he is planning a “radical and politically risky reorganisation of the NHS”.