[1] With apologies to Freud. ‘Wo es war, soll Ich werden’ – “Where it was, I should become” – is his version of the Enlightenment goal of knowledge that is in itself an act of liberation – the ego replaces id and so we develop. Here we have the reverse, ‘Where I was, it should become’ – an undoing. The Health and Care Bill 2021 is an act of destruction. Greed and indifference fuel these changes; a wish for continuous exploitation will undo our greatest achievements.
How the ICS will work in practice
The way ‘Accountable Care’ works is through its funding mechanism and the legal duty put on the ICS and all the individual Partners [2] not to overspend their and the system budgets. The sheer size of the ICS is important to allow this to be possible.
Alongside the budgetary control totals [3] , the structure will be built using Payment Incentives for ‘aligned’ services and required percentage spends on ‘integration’ development. With the ‘new models of care’ in place and the absence of any legal duty to provide secondary care services then referral avoidance and the whole range of other efficiency measures as described in McKinsey‘s 2009 paper ‘Achieving World Class Productivity’ [4] can be fully used to try to cut costs. The increased waits and lists of Procedures of Limited Clinical Value (PoLCVs) [5] will increase the number of people willing to pay for care either directly from Private providers or as ‘NHS paying patients’ utilising the NHS or the developing public-private partnerships’ services.
Clinical activity, costs and ‘outcomes’ will be monitored in real time – everything will be developed as a ‘currency’- and ‘best value’ for the system
(possibly decided using IT) will be used to explain away individual decisions not to provide care.
The majority of the limited community spend will be focused on those patients selected as ‘at risk’ of requiring elective secondary care by the predictive Artificial Intelligence algorithm. They must be kept away from any test ordering, hospital admitting doctors.
Squeeze the system control total and watch the system work.
Integrated Care Boards will be able to enter into financial agreements with external parties. They and their Partners will generate income streams; this is already evident at the Royal Marsden Trust, the HCA-UCLH Trust partnership and the Johnson and Johnson- St Thomas and Guys Trust partnership. There are also 65 NHS Trust subsidiaries (2018 figure) [6] currently trading as private companies which could also generate capital income streams, perhaps with private partners, once the ICSs are set up and current capital spending limits relaxed. Essentia, a St Thomas and Guys subsidiary in SE London, is currently a partner in Optimedis COBIC UK and is accredited on the Health System Support
Framework (HSSF).
NHS Trusts and major academic organisations will become ‘anchors’ of place and help with inequalities through preferred employment of local people within their organisations and preferred contracts for local Small and Medium Enterprises using subsidiaries to negotiate this. They could also use their financial resource to leverage finance for local community development and Public Health initiatives.
Community care will be ‘asset- based’ [7] (MacLeod & Emejulub 2014) and digitised, with all digital platform providers only accredited by NHSE if they can support Personal Health Budgets. ‘For profit’ and ‘Not for profit’ providers will be heavily involved and both will be able to receive financial assistance directly from the Secretary of State or bodies to which he has delegated this function. It also seems that many of the huge number of community healthcare apps carry adverts [8] – a new market – which will gain a huge boost described as ‘the rise of the consumer in healthcare’ when apps and devices are linked to Cerner Millenium or similar health information packages [9].
Not having private corporations on the board will not stop any of this.
It is the removal from the remit of PCR 2015 [10] and the CMA [11] that will deregulate the market with the loss of all its labour and environmental protections. PCR 2015 allows procurement without tendering but only within public services, so it seems they need deregulation if they wish to give contracts to private providers. The NHS Provider Selection regime also makes it easier for ‘Any Qualified Providers’ to get accredited and placed on Provider lists, and makes it more difficult to remove them- it will be mandatory for the Secretary of State to impose standing rules on NHS England and ICBs to enable people receiving certain treatments to exercise choice.
National pay scales and collective bargaining will become virtually impossible as each of the 42 ICSs will develop its own plan and outcomes, and will need to provide the services required to achieve them while bound to its own legally agreed budget/control total. There are expectations for ICSs to innovate to achieve sustainability. Also the People Plan requires a flexible, agile workforce that can move between disciplines and the Partners and can be ‘passported’ between NHS and social care and beyond the system. There is an ambition that technology will allow the deregulation of various groups of staff.
Notes
[2] The Provider organisations within an ICS will be called Partners. The ICBoard is a ‘body corporate’. So in North Central London we have ‘North London Partners’.
[3] IC Boards are required to keep revenue expenditure within an agreed range set by NHS England.
[4] See here for the McKinsey paper
[5] They used to be called Procedures of Limited Clinical Effectiveness (PoLCEs) but the immaterial nature of ‘value’ broadens the scope of what can be rationed and allows comparison with activities across the system when decisions are to be made about where to spend the limited budget.
[6] Jan Savage, Marion Macalpine and Carol Saunders ‘How come we didn’t know about SubCos? The growing use of NHS-owned private companies’. Pamphlet 2021
[7] a specific kind of neoliberal community care developed during the Reagan administration relying heavily on ‘assets’ e.g. volunteerism, families and friends, charities etc and the use of the market and marketing
[8] Healthcare apps are booming (53,979 registered on Google) and many/most carry adverts to pay developers, and once apps and health devices are linked to health records it will allow tailored adverts to help care and optimise markets.
[9] As Distie Profitt CEO Cerner UK reported in Digital Health- The challenges of leading Cerner UK during the Covid-19 pandemic 2020.
[10] Public Contracts Regulations
[11] Competition and Markets Authority
Doctors in Unite 