We say NO! to proposed NHS legislation that would restrict access to care and profit global companies

Here is Calderdale and Kirklees 999 Call for the NHS response to NHS England/Improvement’s “engagement” on their proposed NHS legislation.

Please send them your response too. If you agree with ours, you’re welcome to use whatever you like in it. The deadline is Friday 8 January 2021 at midnight and you can either use their online survey form or send an email to england.legislation@nhs.net

If you’re new to all these issues, here’s a much shorter simpler version:

digital-leaflet_response-to-ics-legislation-engagementDownload

We strongly disagree that ‘giving Integrated Care Systems a statutory footing from 2022, alongside other legislative proposals, provides the right foundation for the NHS over the next decade’

Nothing has happened to change our group’s statement in response to the 2019 NHSE engagement on possible legislation for Implementing the Long Term Plan:

“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.”

We strongly disagree that ‘option 2 offers a model that provides greater incentive for collaboration alongside clarity of accountability across systems, to Parliament and most importantly, to patients’

Option 2: “a statutory corporate NHS body model that additionally brings CCG statutory functions into the I[ntegrated] C[are] S[ystem]” is basically an Accountable Care Organisation. The claims you make for it – in terms of providing a greater incentive for collaboration and clarity of accountability across systems, to Parliament and to patients – are misplaced to the point of dishonesty.

Turning Integrated Care Systems into Integrated/Accountable Care Organisations, as in Option 2, would enable American health insurance and digital technology companies (which dominate the supplier lists in the Health Support Services Framework) to take up near-monopoly positions running the NHS. Thanks to years of groundwork they are now poised to do, if this proposed legislation is enacted.

This proposed legislation is the end game of at least a decade’s steps towards the privatisation of NHS Commissioning. We would like to remind you that from the start this prospect has attracted the keen attention of US health insurance and health systems support companies.

In September 2010 three representatives of the huge American health insurance company United Health attended a lobbying meeting that Andrew Lansley gave to the Commissioning Services Industry Group. Six months later United Health refocussed its UK business to concentrate solely on commissioning support in areas such as data analytics, demand management and medicines management, stating this could play a key role in helping the NHS make £20bn in “efficiency savings”. The cuts-driven agenda of privatised NHS commissioning was clear from the start.

The United Health connection solidified when Simon Stevens, as Chief Exec of the NHS Commissioning Board, set up the secretive Commissioning Support Industry Group – chaired and funded by United Health. In 2016 the Group drew up an approved suppliers list (Lead Providers Framework) for a £3bn – £5bn privatisation of Commissioning Support Units, with United Health as the lead provider for nearly all the Commissioning Support Units.

In 2018, the NHS Commissioning Board replaced the Commissioning Support Lead Providers Framework with the Health Systems Support Framework. The new Framework’s explicit function is to provide 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.”

In this way, NHS Commissioners are already required to pay private companies to do the work for them of setting up and using a commercial insurance-based model of healthcare provision, within the NHS shell of Integrated Care Systems.

Now you want to cement this privatisation through proposed legislation to abolish Clinical Commissioning Groups and hand their strategic commissioning functions to a new statutory corporate NHS body – that is basically the Accountable Care Organisation previously proposed by the Department of Health and Social Care, before they decided to abandon the name in an attempt to shed its American connotations which campaigners had drawn attention to.

As explained more fully below, exempting private companies from competition rules and regulation as this proposed legislation would do (Para 2.61, Integrated Care Next Steps), is almost certain to establish United Health’s subsidiary Optum as a near-monopoly provider of the strategic commissioning functions of Integrated Care Systems.

This would mean handing the company the power of deciding what NHS and social services should be provided, when and how and to whom.

Optum’s commissioning processes are already entrenched in the NHS as a result of “invitations” by NHS England to scores of Clinical Commissioning Groups to work with Optum to adopt their insurance-based, cost-cutting commissioning processes as the basis for turning Sustainability and Transformation Partnerships into Integrated Care Systems.

We have seen from the government’s response to the Covid19 pandemic that the corrupt and secretive handing out of £bns of public money to companies – often with financial and personal connections with the Conservative Party – has resulted from the emergency suspension of requirements to publicise contract opportunities so that companies are able to bid freely for them.

We are alarmed that a similar process could easily result from NHSE/I’s proposal to abolish the requirement for competitive tendering of contracts. Collaboration is a very nice buzz word, liberally scattered throughout your 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.

Undermining accountability
And far from increasing accountability to patients, privatising NHS Commissioning and putting it in the hands of US companies would undermine accountability to patients and endanger clinicians’ ability to practice evidence-based medicine, where treatment is decided on the basis of dialogue between clinician and patient about the best option in the patient’s individual circumstances.

The establishment of Sustainability and Transformation Partnerships, and their development into Integrated Care Systems, has already introduced actuarial processes into NHS commissioning, by American companies eager to pursue the profits to be gained from from the massive guaranted NHS funding stream – and in particular 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.

Option 2 in 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.

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. So much for increased accountability to patients.

Barcoding patients to track their costs to the NHS
Patient Level Information Costing Systems – which are central to Integrated Care Systems/Organisations – are another threat to accountability to patients. Patient Level Information Costing Systems 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. 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 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.”

This is central to the Accountable/Integrated Care model. Clinicians have told us that prohibiting treatment options on the basis of financial restrictions undermines their duty of care to their patients. It is certainly not going to increase their accountability to patients or to their own ethics.

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.

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.

United Health’s subsidiary 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.

The 20 week Optum Course for Dorset was about how linking and analysing data is used to:

“influence the behaviour of professionals delivering care and individuals managing their own lives”

It 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.

Para 2.51 p 21 in the Integrating Care Next Steps document proposes “a more flexible legislative framework than currently exists” for data sharing, in order to “ build on the experience of data sharing during COVID”. We strongly disagree with this proposal.

First, the existing legislation is entirely clear: if there’s a lawful basis and legal duties (e.g. of care and confidentiality) are met, then data can be shared. If not, then it can’t. What more “flexibility” do you want? Maybe rather than pushing to change rules that are there to protect the people – not the “health and care system” – they exist to serve, NHSEngland/I/X would do better to ensure the investment, processes, staff support and public trust are in place to help health and care interoperate.

Second, data sharing during COVID has been so lacking in transparency and accountability that it took the threat of legal action, supported by thousands of citizens, before NHS England published the contracts it had struck with tech firms to deliver the Covid-19 data store. As you know, OpenDemocracy are now considering a judicial review to compel the government to hold a full public consultation before it awards a longer-lasting data store contract after the pandemic.

Third, the proposals for more flexible legislation to build on Covid-19 data sharing would increase NHS dependence on private tech companies in a way that would essentially make it digital tenant to a global corporate landlord. We agree with Lina Dencik, the co-director of the Data Justice Lab at Cardiff University, who warns that as a natural monopoly, once the NHS is locked into such a relationship it is unlikely to be able to extricate itself.

Basically your Option 2 proposals would cut our access to NHS treatments on the basis of actuarial judgements, divert a large part of the NHS funding stream into private profits and irrevocably hand control of NHS commissioning and the data sharing it depends on to global corporations.

We strongly disagree that, ‘other than mandatory participation of NHS bodies and Local Authorities, membership should be sufficiently permissive to allow systems to shape their own governance arrangements to best suit their populations needs’

As already stated, we do not think there is any justification for dismantling the NHS into Integrated/Accountable Care Organisations, whether you describe them as “a statutory corporate NHS body model that additionally brings CCG statutory functions into the ICS”, or use some other expression.

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 an updated NHS Reinstatement Bill that includes putting medical innovation into public hands – to prevent the hijack of the NHS by life sciences, big pharma and digital technology companies.

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.

We strongly disagree that, ‘subject to appropriate safeguards and where appropriate, that services currently commissioned by NHSE should be either transferred or delegated to ICS bodies’

See response to q 6