Author: docjon1415

Doctors in Unite have grave concerns about the Police, Crime, Sentencing and Courts Bill 2021.

We believe that the measures proposed in the bill will erode civil liberties and severely undermine the right to protest, a cornerstone of UK democracy.

The Bill will give the Home Secretary:

“the power, through secondary legislation, to define and give examples of “serious disruption to the life of the community” and “serious disruption to the activities of an organisation which are carried out in the vicinity of the procession/assembly/one-person protest”

“Serious disruption” is highly subjective and in our view is no basis on which to enforce the law.

Even now, before the proposed measures become law, there are regular examples of heavy-handed policing which very rarely result in prosecution or conviction of the officers involved. The disgraceful behaviour of the police during the vigil for Sarah Everard on Clapham Common on March 13^th 2021 and the ten thousand pound fine handed to an NHS nurse for organising a perfectly safe socially distanced protest against the Governments 1% pay award to health workers both serve as a warning of things to come should this Bill pass successfully through Parliament. 

The protest tactics of Extinction Rebellion and Black Lives Matter have been cited as examples of serious disruption, despite the fact that these protests have been entirely peaceful.

Protest is often the only way that citizens are able to express themselves when those in power fail to listen. People are outraged at the government’s catastrophic failure over the pandemic, its slap-in-the-face 1% pay offer for nurses, its failure to address structural racism and its continued support for the fossil fuel industry. We could be forgiven for thinking that the government are seeking to restrict the right to protest to prevent an outpouring of anger onto the streets as the country begins to emerge from lockdown.

The disruption to people’s lives caused by the government’s failure to listen is much greater than the temporary disruption caused by a demonstration.

Restriction of the right to protest historically arises from increasingly authoritarian governments to quell public unrest, it has no place in a democratic society.

The outrageous jail sentences proposed, of up to ten years for toppling a statue, will disproportionately affect the rights of marginalised communities such as migrants to protest as they can be deported if given custodial sentences of more than one year. This Bill will effectively silence them.

This Bill must be defeated and the right to protest and freedom of speech preserved for today and for future generations.

“These are the sickest, the ones where over 40% will die……It’s the Uber driver, bus drivers, restaurant workers, delivery people, security guards.  People think its old people dying.  Everyone I’m looking after (in ICU) is in their 50’s and 60’s.”

These are the words of Dr Helen Simpson, Consultant Endocrinologist, who is volunteering in UCH Hospital Intensive Care Unit, quoted in the Guardian on 12 February 2021.  Her words reflect what we have now long known about the pandemic: front-line essential workers, those who have kept the country going throughout, are much more exposed to Covid-19 and are dying at disproportionate rates than other workers. 

The ONS recently released its updated report on Covid-19 related deaths by occupation (up to 28 December 2020).  It paints a stark picture of high death rates for essential workers, who have had to go to work, many times higher than others who are able to work from home, such as senior managers, directors and professionals. 

The ONS report is timely: it was published 2 days before the Joint Committee for Vaccination and Immunisation (JCVI) published its strategy for vaccinating the country against Covid-19, which has been endorsed by the government.  Because of the initial shortage of vaccines, and the logistical challenges of vaccinating the entire adult population, the strategy is quite rightly based on prioritising those at greatest risk of dying.  Age by far the greatest risk factor: people over 70 are at very high risk while those over 80 are at extremely high risk.  Care home residents are a very high priority, as they are at very high risk.  Health and social care workers have also been allocated high priority – they are at high risk of exposure to infection and of spreading the infection to those they care for.  Next in line are those who are “clinically extremely vulnerable” (CEV), people with serious medical conditions such as cancer, immune disorders, organ transplants and severe disease of vital organs.  The rationale for this is that CEV people have about the same risk of dying from Covid-19 as do people aged 70-79, from data from the first wave last year, according to the JCVI.

At the time of writing the vaccination programme has been very successful to date; it has vaccinated the great majority of people in the above categories, so called groups 1-4 of the JCVI priority list.  However, it is very concerning that the rate of vaccination of BAME people within groups 1-4, is much less than the rate for whites, i.e. about half in some ethnic groups.  BAME people are at considerably higher risk of dying of Covid-19 so this is especially worrying. 

We are at the point now of beginning to vaccinate the next two priority groups in the JCVI’s list: group 5, who are people over 65 years of age, based on their “absolute increased risk” which is considered to be higher than the risk for those who have underlying health conditions, who constitute group 6.  Groups 7, 8 and 9 are people aged 60-64, 55-59 and 50-55 years respectively.  The rest of the population will be vaccinated after this.

The table below shows the priority groups, and the number of people in each group:

The problem is that when it comes to essential workers, the JCVI abandons the methodology of determining priority according to absolute increased risk of death.  According to the death rates in the ONS report, many groups of essential workers have much higher absolute death rates than both people aged 65-69, and those aged 16-64 with underlying health conditions.  This is especially true of male workers, while women working in essential jobs have risks roughly equal to those in priority groups 5 and 6.  Some women workers however, ie, machinists in garment factories, have four times the average death rate.  The graphs below illustrate the various deaths rates. 

Please note health and social care workers, who are at high risk, are not included as they are already in the first four priority groups of people being vaccinated.

Death rates for essential workers (men) *

(average rate is in purple on right)

Death rates for essential workers (women) *

(please note the different Y-axis values, i.e. half of that in the graph for men)

*ONS occupational categories are broad, for a detailed breakdown see here

JVCI has the following to say about occupational vaccination:

The committee considered evidence on the risk of exposure and risk of mortality by occupation. Under the priority groups advised below, those over 50 years of age, and all those 16 years of age and over in a risk group, would be eligible for vaccination within the first phase (i.e. all 9 priority groups) of the programme. This prioritisation captures almost all preventable deaths from COVID-19, including those associated with occupational exposure to infection. As such, JCVI does not advise further prioritisation by occupation during the first phase of the programme.

Occupational prioritisation could form part of a second phase of the programme, which would include healthy individuals from 16 years of age up to 50 years of age, subject to consideration of the latest data on vaccine safety and effectiveness.

This is moving the goalposts.  JCVI cannot on the one hand argue that absolute risk of dying should determine priority when this is due to age and underlying medical condition, and then on the other hand say that risk of dying does not apply when it is due to occupational risk.  The reasons behind the high death rates are surely irrelevant in terms of determining who gets priority for vaccination.  If we are vaccinating people according to risk of dying, that is what we should be doing, across the board.  The “first phase” referred to in the above quote, includes all 9 priority groups, and yes it will ultimately cover almost all preventable deaths (because it covers the great majority of the at-risk adult population i.e. over 38m people), but this will take many more weeks.  One could apply the same logic to those with underlying medical conditions and advanced age, and say, “Don’t worry once we have vaccinated everyone over 50, you will also be covered, we don’t need to prioritise you”.  That would clearly be nonsensical.

Many essential workers have death rates more than double those of people with underlying medical conditions and well in excess of people aged 65-69.  It also cannot be right that a worker in a processing plant, and a senior manager or professional of the same age, have the same priority for vaccination, when the worker has over six times the risk of dying from Covid-19.  Many essential workers are poor and many are black or Asian and it is striking that this double standard is being applied to them.  One cannot imagine company directors and stockbrokers not getting vaccine priority if these death rates were reversed and they were the ones dying disproportionally from Covid-19.

The news that people with learning disabilities have now been prioritised for vaccination by the Joint Committee on Vaccination and Immunisation (JCVI) is to be warmly welcomed (Guardian 25 February 2021).  The JCVI has done so “to ensure those most at risk of death or hospitalisation are prioritised” according to its statement, and a government source is quoted as saying “this is ultimately about who most likely to get seriously ill and die from this disease”.  Why then have the JCVI and the government at the same time once again ruled out prioritising essential workers for vaccination, when their risk is also very high and certainly much higher than many people in groups 5 and 6 of the JCVI priority list who are now being vaccinated? 

An equitable prioritisation programme of vaccinations demands essential workers should be immunised as the next priority group.

There are in addition several other important reasons for prioritising essential workers: 

• While clear evidence of reduced transmission following vaccination is not yet available, early indications are that the vaccines do reduce transmission which is very much the hope of all of us, including the JCVI.  If this does prove to be the case, immunising essential workers will have a greater impact on reducing transmission, because they are much more likely to live in overcrowded housing, and deprived communities where social distancing and other mitigation measures are more difficult.  In addition, the more essential workers are protected the less transmission there will be in their workplaces which may be high risk, such as meat packing plants and garment factories.

• Although the great majority of deaths have been in people aged over 50, there have still been several hundred deaths of those under 50, and many thousands of Covid-19 infections in this age group, 5-10% of whom will have progressed to suffering debilitating Long Covid. 

• There also appears to be a clear impression amongst front-line clinicians like Dr Helen Simpson that younger patients are getting sicker in the second wave, perhaps linked to the greater transmissibility and virulence of the new mutations.  There is no data yet on this, but there have been a number of similar reports of patients in their 40s and 50s in intensive care recently.

• It will take many more weeks to vaccinate another 25m people, by which time many thousands of new infections will have occurred among essential workers because of their greater exposure, both to the public as part of their jobs, and/or to their fellow workers because of the nature of their work, and it must be said, poor compliance with health and safety requirements in the workplace by employers.  Every week the PHE weekly surveillance report notes scores of outbreaks in the workplace; in the first week of February 2021 there were 112 workplace outbreaks reported to PHE.

• As noted above many essential workers are black or Asian and priority for vaccination would go a long way to protecting their families, especially those in overcrowded multi-generational households and the local community from the virus.  This would be a very concrete way of addressing some of the large disparities in deaths suffered by black and Asian people, and send a clear signal that their lives matter to all of us.

• A nationally recognised campaign to immunise all essential workers would also make it plain to everyone, our collective appreciation of the role they have played throughout the pandemic on the front line, in ensuring that there is food, transport and essential services for all of us.  Many essential workers are poorly paid and many are in precarious employment; offering them early protection against the virus would ensure they could continue working safely without putting the families and colleagues at work at risk.

• The recent report by the Joint Biosecurity Centre (JBC) states there is a “perfect storm” of factors, resulting in stubbornly high infection rates, which applies in deprived areas of the country: low wages, cramped multigenerational housing, failures in the test and trace service, lack of support for isolation, and public facing jobs.   These factors are not going to be corrected any time soon, and vaccination would offer protection to these vulnerable workers and their communities. 

• Without prioritisation, and a publicity campaign, many essential workers will end up not being vaccinated for all the usual reasons: poverty, reduced access to health care, language difficulties for many, etc.  For once we could ensure that the “inverse care law” (those most in need get the least care) does not apply.

26 February 2021

References

Occupational risk

Age

Learning disability risk

Different figures have been published for death rates, but a government review of Covid-19 deaths of people with learning disabilities published in November 2020, stated an age and sex standardised death rate of 6.3 times the general population during the first wave of the pandemic.  Black and Asian people with learning disabilities appear to have twice the death rate of white learning disabled people.  The ONS recently reported the risk of death involving COVID-19 was 3.7 times greater for both men and women compared with people who did not have a learning disability, for the period January to November 2020.  An average figure of five times the average risk has therefore been used for men and for women.

Risks for diabetes, COPD, hypertension and obesity have been calculated from the following sources and multiplying by average risk.

Diabetes risk

Hypertension risk

COPD risk

Obesity risk

GP magazine reported yesterday: A subsidiary of a giant US healthcare company is set to hold nearly 1% of GP contracts in England – making it the country’s largest provider of NHS primary care with around half a million patients.

The article quotes Jackie Applebee, Chair of Doctors in Unite, “‘The public are constantly told that the NHS is not being privatised. The advent of Centene onto the general practice landscape reveals yet again, that this is a lie. In reality the NHS is being parcelled up and sold off under the radar.’

The article can be found here

It is with the deepest disappointment and gravest foreboding that we received the news today that AT Medics is to be taken over by Operose Health, a subsidiary of US Health Care  company Centene

AT Medics is the largest provider of primary care services to the National Health Service and operates General Practices across London mainly through Alternative Providers of Medical Services (APMS) contracts.

Involvement of the private sector in the provision of NHS services has led to fragmentation of care, to the detriment of patients. This has been thrown into sharp focus by the COVID 19 pandemic. The National Test and Trace programme, run by the likes of Serco, Sitel and Deloitte has been an abject failure, and nowhere have the consequences of outsourcing and fragmentation been so tragically shown to be a disaster as much as in social care, when for lack of national planning and oversight, many elderly residents of care homes so needlessly died. 

We have been warning for years that US health care firms are circling to swoop on the NHS. Our fears are dismissed by politicians and senior NHS managers. The public are constantly told that the NHS is not being privatised. The advent of Centene onto the General Practice landscape across London reveals yet again, the this is a lie. In reality the NHS is being parcelled up and sold off under the radar. 

The leaked white paper on Integrated Care Systems, with it’s promise to end competition will only hasten the demise of the NHS into a US style HMO system as contracts are handed to private companies, without scrutiny. This practice already has precedent and has been common throughout the COVID 19 pandemic.

US style health care is nothing to aspire to they spend more on health care as a share of the economy, nearly twice as much as the average OECD country, yet have the lowest life expectancy and highest suicide rates among the 11 nations.

We demand that the affected CCGs terminate the APMS contracts held by AT Medics and now Overose in line with Para 54.1 of the Standard APMS Contract, October 2019 which states:

“The Contractor shall not sell, assign, sub-contract or in any way dispose of any of its rights or duties under the Contract in relation to the Services or any part thereof without the prior written authorisation of the Commissioner and subject to such conditions as the Commissioner in its absolute discretion may impose.”

Further we demand that outsourcing to the private sector is stopped and that the NHS is returned to the publicly funded, publicly provided, comprehensive health care service, available to all, free at the point of delivery that Nye Bevan intended.

NHSE/I recently published a consultation document on the “Next steps to building strong and effective integrated care systems across England”. This response exposes the fundamental problems of a market based health care system in trying to deliver integrated care.

1. Overview

Publication of the next steps document during the covid-19 pandemic comes at a remarkable moment. Significant shortcomings have been exposed in the NHS¹, in the systems for communicable disease control and public health,² in the procurement system³ and in the social care system.⁴ The lack of hospital and ICU capacity have been major drivers of national lockdowns in March 2020 and January 2021 and the causes of severe winter pressures in previous years.

At the same time, the pandemic has demonstrated the obstacles created by market bureaucracy and heavy-handed and centralised market regulation which have developed over decades in the NHS.

The document hints at positive effects of the pandemic (paragraph 2.1) and refers in general terms to some of them (e.g., 2.72), which have played a part in “increas[ing] the appetite for statutory ‘clarity’ for ICSs and the organisations within them.” (3.8). It also recognises “the persistent complexity and fragmentation” which is rightly complained about (1.3).

This is largely the product of reforms premised on competitive relations and contracting among health bodies. Finally a new anti-competition consensus appears to have emerged in NHS reform⁵ which has found its way, though problematically, into the document.

But as David Lock QC has said in 2019: “The big picture is that you have a market system. If you do not want a market system and you want to run a public service, you need a different form of legal structure.” And this obvious truth raises fundamental questions, which the document seems to glimpse, but which it is unwilling to grasp.

Why, for example, continue to insist on running health organisations as businesses if the aim is collaboration instead of competition? How should needs-assessment and population planning be undertaken if the aim is to secure comprehensive health and social care for geographic areas? Where should they be located and on which bodies does the statutory duty of universality fall? How can major political questions surrounding resource distribution be undertaken consensually outside established political processes? Equitable access and solidarity require risk-pooling and a community response.

Rather than rising to the challenge of these questions in ways which could reliably “provide[] the right foundation for the NHS over the next decade” (page 31), the document puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market-based framework and undermine risk-pooling, even when proposing legislative change; much essential detail is omitted.

As they stand, the proposals seek to achieve integration by focussing on increasing freedoms of the various bodies involved in commissioning and contracting. They rely on general exhortations to counter deregulation. Laudable “fundamental purposes” inform an “aim” of “a progressively deepening relationship between the NHS and local authorities”. Three “important observations” which may or may not be aims relate to more local decision-making, more collaboration and economies of scale. A “triple aim” duty of unspecified strength relates to “better health for the whole population, better quality care for all patients and financially sustainable services for the taxpayer” (1.3, 1.8, 1.9, 3.3).

The approach however leaves substantially unchanged the legal powers of the many incorporated bodies active in the health care market among which collaboration is expected but from which disintegration has spread. If the aim is “rebalancing the focus on competition” (3.3) a concrete.

administrative alternative is required. None is offered. Seeking to promote greater integration whilst retaining commercial autonomy will not work.

In summary, the proposals:

• leave in place the purchaser-provider split and commercial contracting;

• continue the ability to give further contracts to private companies, including, it seems, integrated care provider contracts;

• provide no response to the finding of the National Audit Office in 2017 that “The Departments have not yet established a robust evidence base to show that integration leads

• to better outcomes for patients”;

• favour no controls on ICS membership;

• give immense and barely-regulated power to monopoly providers and clinical networks

• contain no controls on the composition of “provider collaboratives”, which could include, for example, large private hospitals;

• are silent on public accountability mechanisms at a system level, and at the non-statutory “place” level;

• repeal section 75 of the 2012 Act, revoke some of the ‘section 75 regulations’ and remove commissioning of NHS healthcare services from the Public Contracts Regulations 2015 – which are welcome – but are silent on the safeguards against corruption and conflicts of

• interest, and some of the section 75 regulations would seemingly be retained;

• emphasise the importance of strategic needs assessment – which is also welcome – but do not require the assessment to frame provision or to qualify the power of providers and clinical networks;

• do not appear to make ICSs responsible for all people in an area, and there are unresolved difficulties for integrating health and social care because of different funding bases for different populations;

• are silent on whether individuals on GP lists will transfer to an ICS body, a provider or a provider collaborative;

• are unclear on the fate of CCGs in Option 2;

• contain no explanation of how capital investment strategies will operate, and whether charges on capital, including PFI charges, will change;

• do not address the powers of NHS foundation trusts;

• are unclear on how local authority public health funding will be protected;

• are unclear on how social care funding will be protected, and how the currently different funding bases for health and social services will be addressed;  

• are silent about workforce planning;

• envisage, but are unclear about, moving staff between organisations, and their terms and conditions.

We discuss the details in the following two sections.

2. ICSs during 2021/22 and before legislation

The document seems to have two purposes: to further progress ICSs and the merger of CCGs ahead of legislation; and to explain changes to the NHSE/I’s legislative proposals published in September 2019.

Our understanding of what an ICS will be and do, before legislation, is set out in the below.

What will an ICS be and do before legislation – as far as we can make out?

An ICS will not have legal form and will consist of:

• provider organisations as part of one or more undefined and self-determined “provider collaboratives” operating within and beyond the ICS playing “an active and strongleadership role” and being “a principal engine of transformation”(2.4, 2.31, 2.63); and

• “place-based partnerships”, defined by each ICS but seemingly comprising providers of primary care, community health and mental health services, social care and support, community diagnostics and urgent and emergency care – i.e., excluding secondary care, but including local authorities, Directors of Public Health and Healthwatch, and “may” include acute providers, ambulance trusts, the voluntary sector and other – undefined – partners (2.31, 1.16).

• It will receive a “single pot budget” which would comprise “current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, central support or sustainability funding and nationally-held transformation funding that is allocated to systems” (2.40), and will decide how that budget should be delegated to local “places” within the ICS.

• Providers will “agree proposals developed by [undefined and self-determined] clinical and operational networks” and will “implement resulting changes” including “implementing standardoperating procedures to support agreed practice; designating services to ensure their sustainability; or wider service reconfiguration”; and will “shape the strategic health and care priorities for the populations they serve, and new opportunities – whether through lead provider models at place level or through fully-fledged integrated care provider contractual models – to determine how services are funded and delivered, and how different bodies involved in providing joined-up care work together” (2.11, 1.44).

• The ICS will undertake more strategic needs assessment and planning than CCGs can do, resulting in “the organisational form of CCGs…evolv[ing]” (2.62-2.63).

• The ICS will be subject to governance and public accountability arrangements that are said to be “clear but flexible”, but will not be statutory. (2.28-28, 2.19)

We make a number of key points under the following headings:

(1) Strategic needs assessment

The emphasis on strategic needs-based assessment and planning is welcome, yet there will be no single body which has the responsibility to carry it out and no legal mandating of it. This is likely to lead to buck-passing. Perhaps more importantly, it is also likely to lead to needs-based planning being overridden by increasingly powerful monopoly providers having pivotal influence over a single budget, and over its allocation both for non-secondary care services to undefined “places” with no statutory identity, and for secondary (and tertiary) care.

Moreover, it seems highly unlikely that services provided would be based on the needs assessment, because clinical networks are expected to carry out “clinical service strategy reviews on behalf of the ICS” and “develop proposals and recommendations” which providers will agree. Indeed, “[c]linical networks and provider collaborations will drive…service change” (2.26, 2.11, 2.72). No tie-in to the strategic needs assessment is proposed, let alone a requirement for it to frame provision.

Public health experts have traditionally performed the functions of needs assessment, facilitating service development and service planning. However, public health sits outside of health services and is further fragmented between local authorities and the Secretary of State (Public Health England, to be replaced by another non-statutory body, the National Institute for Health Protection) as a result of the 2012 Act.

Clinical Support Units provide information and support for commercial contracting. They are not substitutes for public health, are not integrated into CCGs or local public health departments, and do not inform strategic needs assessment and service planning.

(2) The single pot budget

It appears – certainly before, and perhaps after, legislation – that ICSs will not be responsible for all people within an ICS area. That term – an ICS area – is conspicuously absent from the proposals. The CCG membership model (‘persons for whom they are responsible’) cannot be changed without legislation and so will presumably be ‘scaled-up’ to cover all the CCGs involved.

We have previously expressed⁶ concern about how Accountable Care Organisations would have been able to integrate health and social care services because their funding would have been for a different population (GP lists versus local authority), and would not have health service funding allocated for unregistered CCG residents who might be eligible for local authority social services. This concern still applies in relation to ICSs, including provider collaboratives and place-based partnerships, both with and without legislation, and with and without integrated provider care contracts.

In addition, the bases upon which resources will be allocated to secondary (and tertiary) care and to place-based partnerships, and within those partnerships are entirely unclear. This is presumably deliberate. Already there has been a marked decrease in administrative accountability for spending, and multiple contracts and subcontracts – which will continue – make it increasingly impossible to ‘follow the money’, let alone to assess the costs of contract administration. Detailed financial reporting to NHSE/I is obviously essential and may be provided for, but public transparency in funding as between primary care, community and mental health services, and acute, secondary and specialist care, including sub-contracting, is also essential.

(3) Provider collaboratives

No control is proposed over the composition of these collaboratives. They could and presumably will consist of private as well as public providers, e.g., of mental health services, residential and nursing care, acute hospital care and pathology services. The potential inclusion, for example, of large private hospitals, which have been contracted during the pandemic, needs to be clarified immediately. No control is proposed over the granting of contracts to providers within thesecollaboratives, who may in fact be distant from and have no connection with the local community and be subject to commercially-driven mergers, acquisitions and closures that threaten patient care.⁷

Full integrated care provider contracts can be awarded, though there is no reference to the House of Commons Health and Social Care Committee in June 2019 having “strongly recommend[ed] that legislation should rule out the option of non-statutory providers holding an ICP contract [in order to] allay fears that ICP contracts provide a vehicle for extending the scope of privatisation in the English NHS”. In September 2019, NHSE/I acknowledged this and stated that it supported the recommendation. If private companies are not likely to be awarded such contracts, then what is lost by legislating to that effect? And what prevented a clear statement to that effect being made in this document?

Neither is there any reference to the HSC Committee’s recommendation that “ICP contracts should be piloted only in a small number of local areas and subject to careful evaluation”.

(4) ICS membership

There are two potential aspects in this regard.

The document proposes for legislative change Option 2 that the ICS body should be able to appoint such members to the ICS body as it deems appropriate “allowing for maximum flexibility for systems to shape their membership to suit the needs of their populations” (3.19). It seems that this will be possible de facto before legislation, e.g., via the unspecified provider collaboratives. This risks giving private companies influence over the allocation of NHS funding: “they are there to make money from the NHS” in the words of Dr Graham Winyard – and should not be admitted as members. Yet the document is silent on this point.

As for patients, the document is silent on whether individuals on GP lists will transfer to any provider (e.g. under an integrated care provider contract), or even to a provider collaborative – or, after legislation based on Option 2, to an ICS body; and, if so, how that would be achieved and whether individuals would have any choice in the matter. In addition, will individuals be able to move from one ICS to another? And what happens, for example, if an individual is on the list of a GP (or provider or provider collaborative) within the ICS, but lives in a local authority area within another ICS and requires social care?

NHSE/I should clarify these issues as soon as possible.

(5) Public accountability

ICSs will be making major resource allocation decisions, which will often be controversial. Transparency and scrutiny will be critical. However, the document says nothing about how current public accountability requirements and mechanisms will work in an ICS context. These mechanisms are based mainly around CCGs and local authorities, but in reality these bodies will no longer be the decision-makers. Actual decision-making will be de-coupled from legal functions and the effectiveness of public accountability will be diminished in the process.

(6) Competition and contracting

Proposals to remove market competition, compulsory contracting and the commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 – which are welcome – cannot happen without statutory change; the rights of private providers and the purchaser-provider split remain in place. The work-arounds continue.

(7) Social care

Adult social services are means-tested. Health services are not. Providers of social care and support are said to be included in place-based partnerships, but the allocation of resources to and within the partnerships is entirely unclear. There is no mention of any safeguards to prevent services which are currently free from being re-designated as social care and so subject to means-testing and possible charges.

(8) Public health

Local authority public health will fall within place-based partnerships. As for other services covered by these non-statutory partnerships, there is no mention of how protecting public health funding will be achieved in the face of the power of provider collaboratives and clinical networks operating at the level of the ICS and beyond. Representation by DPHs and other local authorities is unlikely to be enough.

(9) Workforce planning

The next steps document is silent about work force planning. Lack of doctors and staff is already a serious issue after years of fragmentation, lack of investment and, appallingly, absence of a strategy: the Kings Fund described it recently as “a workforce crisis”. NHSE/I need to be clear about how attempts to improve this critical function would operate in the ICS context.

(10) Moving staff and their terms and conditions

It is proposed that there should be “frictionless movement of staff across organisational boundaries” (bizarrely in the context of data and digital technology, page 20). This is capable of different meanings across a spectrum, but nothing more is said about this, nor on the terms and conditions of staff in the ICS context. Much more information should be provided.

3. ICSs after legislation

There is much less information on legislative changes in the next steps document than was contained in NHSE/I’s September 2019 document entitled The NHS’s recommendations to Government and Parliament for an NHS Bill. The next steps document lists some of thoserecommendations and states, oddly, “We believe these proposals still stand” (3.3, 3.4). This statement makes it unclear whether they continue to be proposals.

The next steps document proposes two options for legislation.

Option 1 would establish the ICS as a mandatory statutory ICS Board in the form of a jointcommittee of NHS commissioners, providers and local authorities with an Accountable Officer, and with one CCG only per ICS footprint which would be able to delegate “many of its population health functions to providers” (page 29).

Option 2 would set up a new statutory ICS body asan NHS body by “repurposing” CCGs, taking ontheir commissioning functions, plus additional duties and powers, and having “the primary duty…to secure the effective provision of health services to meet the needs of the system population, working in collaboration with partner organisations”. It would have “flexibility to make arrangements with providers through contracts or by delegating responsibility for arranging specified services to one or more providers”. It would have a board of representatives of system partners (NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer as a minimum) with the ability to appoint such other members as the ICS deems appropriate “for maximum flexibility for systems to shape their membership to suit the needs of their populations” (page 30).

NHSE/I prefer Option 2.

Most of the points we have made pre-legislation continue to apply. We expand on some of those and add to them as follows:

(1) Major reorganisation

It is striking that despite the apparent opportunity for primary legislation following the Queen’s Speech neither Option grapples with the fundamental questions posed in the Overview above, which flow from the anti-competitive consensus (if such there be). This might be because NHSE/I wish to avoid being seen to be proposing a major reorganisation. But this is exactly what is happening, even without legislation.

In September 2019, NHSE/I stated:

“The Select Committee [in July 2019] agreed that NHS commissioners and providers should be newly allowed to form joint decision-making committees on a voluntary basis, rather than the alternative of creating Integrated Care Systems (ICS) as new statutory bodies, which would necessitate a major NHS reorganisation.” (emphasis added)

(2) Competition and contracting

No legislative changes are proposed to the purchaser-provider split. Whilst repeal of procurement rules under section 75 of the 2012 Act and removal of commissioning of NHS healthcare services (only) from the Public Contracts Regulations 2015 are welcome, the document is silent on safeguards against corruption and conflicts of interest.

It is also important to recall that in September 2019 NHSE/I stated that it would retain a number of the provisions of the NHS (Procurement, Patient Choice and Competition) (No.2) Regulations 2013 – commonly referred to as the ‘section 75 regulations’. Of particular worry, exacerbated by the covid-19 pandemic, is retention of “the requirement to put in place arrangements to ensure that patients are offered a choice of alternative providers in certain circumstances where they will not receive treatment within maximum waiting times”. The possibility of the use of private providers in these circumstances, rather than increasing NHS capacity, is obvious.

(3) Fate of CCGs

NHSE/I still seem undecided about the fate of CCGs in Option 2. Under both Options, the document states that “current CCG functions would subsequently be absorbed to become core ICS business” (2.64). Yet the document only proposes, in relation to Option 2, to replace the CCG governing body and GP membership, but for some unknown reason does not state that CCGs will be abolished, which presumably they must be, under Option 2, with no replacement.

(4) ICS membership

The document proposes in Option 2 – though we are not clear why this is not a possibility in Option 1 nor de facto from now onwards (see section 2(4) above) – that the ICS body should be able to appoint such members as it deems appropriate. This would be a blatant undermining of the ICS as an NHS body.

In addition, as stated above (section 2(4)), it is unclear whether individuals on GP lists would be transferred to the ICS body.

(5) Missing proposals

• Even though both Options propose primary legislation, the document contains no proposal for ICS-specific public accountability mechanisms, for abolishing the purchaser-provider split, or to give place-based partnerships a legal identity.

• A fundamental omission is how capital investment strategies will operate and whether charges on capital will change. NHS Property Services is now charging market rent for property occupied by Trusts, CCGs and some GP premises. Foundation trusts have autonomy over the property they hold and investment decisions. However, the Private Finance Initiative has left a legacy of major debt in health services and in local authorities. There has been no public scrutiny of the impact of the covid-19 pandemic on PFI contracts, on debt repayments and on renegotiation of the exorbitant rates of interest being paid out as part of the annual payments.

• The powers of FTs are not addressed not least the ability to generate up to half their income from outside the NHS, at a time when public capacity is reducing and waiting lists, e.g., for surgery and cancer care, are growing. Nor is it made clear whether current contracts with large private hospital chains (SPIRE et al.) are long-term and whether they will be involved in provider collaboratives.

• In September 2019, NHSE/I recommended abolishing the prospective repeal of the power to designate NHS trusts that was enacted in the 2012 Act but never brought into force, to support the creation of integrated care providers. The next steps document only mentions this in passing (3.3). It remains unclear if this still being proposed and, if it is, the circumstances in which it could be exercised.

4. Conclusion

These proposals are incoherent, de-regulatory and unclear, and are not equal to the existential threat that is posed by the current government to the NHS as a universal, comprehensive, publicly-provided service free at the point of delivery. This has been amply demonstrated by the government’s response to the covid-19 pandemic which has directed billions of pounds to private companies to provide services that should have been provided by the NHS, Public Health England and local authorities. The proposals allow this to continue and increase.

Neither can the ambition of providing a sound foundation for the next decade be sensibly addressed without considering the inevitable but uncertain changes that will be necessary post-pandemic to the public health and social care systems, and to the functions of local authorities.

The challenge now is much greater than it was in 2019, when the difficulties of getting major NHS legislation through the House of Commons was used as a reason/excuse for not proposing legislation equal to the task of taking the market out of NHS once and for all. We urge MPs who are committed to the NHS as a public service to support scrapping the 2012 Health and Social Care Act in its entirety and to support the NHS Reinstatement Bill which would put back the government’s duty to provide key services, delegated to Strategic Integrated Health Boards and Local Integrated Health Boards.

Footnotes

1. E.g., lack staff, beds and other capacity following inadequate investment and the absence of a workforce planning strategy over many years; inadequate planning and personal protective equipment (PPE); marginalising GPs..
2. E.g., devaluing local authorities and the NHS by centralising and privatising tracking, tracing and testing; spending hundreds of millions of pounds on inaccurate lateral flow tests; by-passing the established system for notifying suspected cases.
3. E.g., spending billions of pounds on untendered contracts, including to companies with no track record.
4. E.g., shortages of staff and PPE; high excess deaths; inappropriate discharge of hospital patients to care homes.
5. “These developments [of STPs and ICSs] represent an important shift in direction for NHS policy. The 2012 Act aimed to strengthen the role of competition in the NHS, consolidating a market-based approach to reform that has been in place since the establishment of the internal market in 1991. By 2019, however, competition rarely gets mentioned in NHS policy. Instead, the Five Year Forward View, STPs, and ICSs are based on the idea that collaboration – not competition – is essential to improve care and manage resources, including between commissioners and providers”. Health Foundation submission to the Health and Social Care Select Committee inquiry into legislative proposals in response to the NHS Long Term Plan, April 2019.
6. Pollock AM, Roderick P. Why we should be concerned about accountable care organisations in England’s NHS. BMJ 2018; 360: k343. https://allysonpollock.com/?page_id=11
7. Care Home Professional, Terra Firma close to £160m care home sale to Barchester Healthcare, 15 November 2019, https://www.carehomeprofessional.com/terra-firma-close-to-160m-care-home-sale-to-barchester-healthcare-report/