“Wo ich war, sollte es werden” [1]

[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


integrated care systems (ics) and the Health and Care Bill 2021-22

Statement by Doctors in Unite

The Health and Care Bill is now in Parliament, and a new Health Secretary in charge. Doctors in Unite branch of Unite the Union opposes the Bill, and calls for MPs and Lords of all parties to vote against it at every opportunity.

The Bill splinters the NHS into 42 separate ‘Integrated Care Systems’ (ICS), each with its own budget set at a level to promote ‘innovation’, and ‘new models of care’ from the US in pursuit of ‘financial sustainability’. This is also known as cuts and rationing, and where they chose to spend will be determined by what they call ‘best value care’ for the system. Local NHS services will be commissioned by, and finances portioned out by, a ‘streamlined’ IC Board, open to the private sector, and committing local authorities to a financial project without real democratic representation, accountability or control.

The Bill will bring the market and marketing, with profits for corporations and investors from ‘the rise of the consumer’ and the ‘certainties of capitated budgets’ in healthcare. Our future healthcare is to be impacted by transnational corporations and banks, and surely it is no accident that a former banker and Chancellor is now Health Secretary, while the Prime Minister’s NHS advisor for integration is the former CEO of Operose (the UK branch of Centene) Samantha Jones. Some 200 companies, at least 30 of them US-owned and prominent in the health
insurance market, are already accredited to help to develop and manage the Integrated Care Systems. They include Operose (which now controls dozens of GP surgeries and community services), Optum (owned by the largest US health insurance firm and previous employer of Simon Stevens- UnitedHealth), IBM, McKinsey, ATOS, Deloitte and Palantir.

Most importantly what will all this mean for patients and for NHS staff, whose wellbeing is essential to provide effective care?

For patients:
● more remote services resulting in fewer face-to face appointments creating a twotier health service, with access tied to an ability to use computers or smart phones

● less contact with GPs with more care given by less skilled and cheaper staff, and with less chance of seeing the same health worker

● growing expectation that patients will ‘self-care’, using phone apps or websites for advice or information

● more risk that services will be cut or rationed, and non-urgent referrals to hospital delayed or refused because of pressure on ICSs to make savings

● faster discharge from hospital without care assessments, and with family carers expected to take on more unpaid care due to lack of community services

● more confidential information being digitised and shared, with no clear protection for patient privacy.

For staff:
● a threat to national agreements on pay, terms and conditions as each IC Board will have their own limited budget and seek to cut costs

● flexible working, with staff redeployed across and even beyond the ICS area, undermining team working, union organisation, continuity of care, and thus creating more ‘work related stress’

● deskilling, as nursing and other jobs are advertised to candidates without the professional qualifications required, but asked to perform using standardised procedures and algorithms

● deregulation, as the Secretary of State will have the power to remove jobs from regulation with an apparent expectation that clinical decisions will be determined by new technology superseding the need for professional judgement and negating the need for staff development.

For democratic accountability and Local Authorities:
● The Secretary of State for Health will assume decision making power to impose local service reconfigurations weakening the power of scrutiny by local authorities

● the right of access by the public to board meetings and papers may also be threatened.

For legal protections:
● Exempting the NHS from the Public Contract Regulations 2015 will remove the associated environmental, social, and labour law protections (ILO conventions guaranteeing Freedom of Association and the Right to Strike). The government plans for the NHS will have reverberations throughout our society. The responsibility for budgetary constraint in our healthcare will be devolved from Government to each ICS, each of their provider Partners and every member of the public for whom they have core responsibility. The threats to staff should ring alarm bells for every trade union with members in the NHS, and the threats to patients should concern everyone.

Let’s stop this Bill now.

Integrated Care Systems threaten patient care, jobs, pay, working conditions and the integrity of the NHS as a public service. we oppose them.

Resolution on ICSs 9 May 2020

Doctors in Unite notes:

  • While attention is focused on Covid, the NHS in England is being rapidly reorganised into 42 regional Integrated Care Systems (ICSs). This will strengthen the role of private companies, including US health insurance corporations, in clinical services and management of the NHS. ICSs will mean more private contracts, more down-skilling and outsourcing of NHS jobs, reduced services and significant spending cuts.
  • The Government plans new legislation to turn ICSs into legal bodies. Their February 2021 White Paper “Integration and Innovation” is based on NHS England proposals, derived from a US model which aims to spend less on care.
  • ICSs will have fixed annual budgets based on area-wide targets, rather than providing the care needed by the individuals who live there.
  • NHS England has accredited 83 corporations and businesses, including 22 from the US, to help develop ICSs. The White Paper will allow private companies to sit on both tiers of the ICS Board: an NHS body including representation from a local authority and open to unspecified others, and a Health and Care Partnership including independent sector partners and social care providers.
  • ICSs will sideline local authorities, threatening the future integrity of social care and reducing local accountability to elected Councillors, let alone patients and NHS staff.
  • NHS providers will be bound to a plan written by the ICS Board and to financial controls linked to that plan.
  • Procurement will be streamlined, eliminating safeguards for compliance with environmental, social and labour laws and the ability to reject bidders with poor track records.
  • The White Paper proposes that unspecified NHS roles currently covered by professional regulation could be deregulated in future due to changing technology.
  • NHS England proposes agile and flexible working with staff deployed at different sites and organisations across and beyond the system.
  • NHS England calls for most NHS funding to be delivered through a fixed block payment, based on the costs of the ICS system plan, whose value is determined locally. Local funding levels could threaten national agreements on wages, terms and conditions. Local pay could lead staff to leave areas where funding is cut, further reducing care.

Doctors in Unite believes:

  • Integrated Care Systems threaten patient care, jobs, pay, working conditions and the integrity of the NHS as a public service. We oppose them.
  • After 30 years of marketisation, it is time to restore the NHS to a fully accountable, publicly run service, free to all at the point of use. As unanimously adopted at Labour Party Conference in 2017, full scale repeal of the 2012 Health & Social Care Act and new legislation for a universal, comprehensive and publicly provided NHS are required.
  • We need a separate, collaborative, publicly funded Social Care Service.
  • Genuine integration based on the wider determinants of health, such as housing, involves more input from local authorities not less.

Doctors in Unite resolves:

  • To immediately report these threats to the NHS and social care, to appropriate Union structures and to find out what action the Union is taking.
  • To press the Union to take urgent action, including using its influence with other unions, the Government and opposition parties, based on the following demands:
  1. An immediate halt to the rollout of ICSs,
  2. An extended and meaningful consultation with the public and Parliament to decide how health and social care services are provided in England.
  3. The introduction of legislation to bring about a universal, comprehensive and publicly provided NHS, free at the point of use and fit for the 21st century.
  4. New technology must be used to improve patient care, not to deskill or replace or performance manage staff, or to deprive patients of face-to-face interaction with clinicians and other care staff that they may want or need.

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