Integrated care systems are part of the government’s plans for NHS organisations, in partnership with local councils and others, to take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve. This seemingly laudable development has the potential to further undermine the NHS, particularly since the Covid-19 pandemic.
The NHS in England is being rapidly and profoundly changed under the cover of COVID-19. There is no public consultation or the necessary legal Local Authority scrutiny on what are emergency measures being made permanent as part of Integrated Care Systems (ICS) development.
The changes include unproven innovation, privatisation and paid for care, and the developing systems present clear opportunities for commercialisation and private investment. The government’s procurement response to the COVID pandemic has been wholly unaccountable and riddled with corruption.
We call for full democratic Local Authority scrutiny and public consultation, as well as democratic representation (i.e. partnership) throughout the incipient ICS structures. We demand a renationalised National Health Service in the longer term.
We passed the following motion at a recent meeting of Doctors in Unite.
Integrated Care Systems:
ICS have been introduced and developed undemocratically, without consultation and with a lack of transparency. Their aim is to impose ‘reduced per capita cost‘ control totals to force unproven and unsolicited innovation, including elements of privatisation and paid for care, in each system’s struggle to meet local population need. This has been NHSE/I’s practice with individual Provider Trusts over recent years. Each ICS will form a new Integrated Care Provider (ICP) organisation. NHS England plans for ICP organisations to be managed through commercial contracts. We therefore call on government to ensure that:
1.Local Authority Scrutiny Committees across England be allowed to fulfil their legal responsibilities to scrutinise fully the significant changes in NHS services that have been initiated without scrutiny under the COVID-19 emergency measures before they become any permanent part of ICS development. If the Committees decide that the changes require full Public Consultation then this must also happen before the changes are allowed to remain. These actions are well established legal process.
2. Some democratic representation is created in the Governance structures of ICSs by: i) an increase in Local Authority Councillor representation on the Governing Bodies so as to match in numbers the NHS representation (Partnership) and ii) full public engagement and involvement for all significant changes and developments in the NHS, with full Consultation as well on the more major issues as decided by the Scrutiny Committees which have been set up in our democracy for this purpose.
3. In the longer term there must be a return to universal risk pooling and funding with renewed efforts for National equity of care and National decisions about affordability. ICS must be replaced by Health Boards with the return to geographically based responsibility for the delivery of health to local populations. The apparatus of the market that divides the NHS must be dismantled. Health Boards as public, accountable bodies would plan and provide the full range of NHS services, with participation from elected councillors, community organisations, Neighbourhood Health Committees as advocated in our paper “Public Health and Primary Care” and trade unions. The quality of services would then be monitored by locally-based independent bodies involving local patients and community groups, with the powers once enjoyed by Community Health Councils.
In recent weeks we have among others seen Boris Johnson, Matt Hancock and members of the Royal family (all of whom it’s safe to guess have never used the NHS) joining in the public applause for key workers. Additionally, there have been a number of structural changes and commitments to increased funding that make it feel as if the strengths of a truly public National Health Service are now being acknowledged, together with an implied criticism of many of the reforms of the last near decade.
Taking over CCGs
On March 23rd it was announced that NHS England was taking on extensive special powers normally held by clinical commissioning groups to support efforts in the face of coronavirus. Dr. Tony O’Sullivan (co-chair of Keep Our NHS Public) commented on the NHS England website: “at this time of national tragedy, we should remember the function of a national health service and how politicians and the seismic restructuring policies in the Long Term Plan have weakened the NHS. I hope that this ends the fragmentation into 42 separate commissioning units and integrated care systems. How wrong that strategy has been. As we welcome some steps towards the re-integration of the NHS in our hour of need, let us not forget the follies that weakened it and that have put NHS staff and the public at risk. We need the NHS to go forward as a single coordinated public service, there for everyone in time of ‘war’ and nurtured once again in post-COVID-19 peacetime.”
Taking over the private sector?
These special powers will be in place until at least the end of 2020, and one of the principal reasons for them was to gain access to independent sector beds. Taking over the independent sector in times of national need is to be applauded. Spain for example has just requisitioned its large private sector. In stark contrast, however, the UK government is paying private hospitals £300 per bed per day. Business analysts have observed that this is a huge boost to independent hospitals. A private hospital working on an NHS tariff at 100% capacity is far better than conducting private medical insurance work at 50% capacity.
The government announced that from April 1st it would “write-off” £13bn of historic debt across the NHS. In recent years financially struggling trusts have been routinely forced to seek emergency bailout loans from the Department of Health and Social Care. Last year, trusts’ total debts reached £14bn, of which £10bn was related to emergency loans. While Matt Hancock declared this a “landmark step” made by himself to help the NHS COVID-19 response, the plans had in fact already been discussed at a January meeting called by NHS England and NHS Improvement, and had been under consideration for at least 20 months.
As tax expert Richard Murphy explains, the government has not written off hospital debt. “All it did was make a book-keeping adjustment. What it actually did was allow NHS trusts to record the sums they had spent for the populations they served as having been funded by central government when previously the government were claiming they had overspent.”
John Lister writing for the KONP website also noted that “it’s like a gang of burglars seeking gratitude after handing back some of the jewels they have stolen. £13.4bn averages to a refund of just £1.3bn per year for the last ten years – far less than the real terms cuts that have been imposed by the virtual freeze on funding while the population and its health needs have grown.” It would be much more valuable to the NHS if the government were to write off the huge outstanding payments for new buildings paid for through the Private Finance Initiative, but strangely, Rishi Sunak does not seem to be stepping forward with this proposal.
Xenophobia is alive and well
Before the pandemic, the UK had only 4100 critical care beds, 6.6/100,000 population compared with Germany’s 29.2. An urgent need to find more ventilators was identified at the start of the outbreak, yet Downing Street chose not to participate in an EU scheme to source such vital equipment, leading to the charge of putting “brexit over breathing”. The government’s attempts to justify this through claims of having accidentally missed a deadline due to communication errors were quickly exposed as groundless by EU officials.
Despite the need for both trust and a unified response to the crisis by members of the public, it is notable that the hostile environment in the NHS has not been lifted. As one member of KONP writing in the British Medical Journal observed, “it is simply not good enough for the UK to add the novel coronavirus to its list of exemptions from charges, which few people will know. To tackle this epidemic and protect everyone’s health, all barriers to accessing NHS treatment – including charges and reporting of debt to the Home Office – should be suspended immediately.”
References to COVID-19 as the ‘Chinese virus’ and promising a reckoning with China after the pandemic are diversions of attention from the failings of our government ministers. Zoonoses (infectious diseases that spread from animals to humans) are linked to climate change and intensive farming methods among other things, and are destined to be a recurrent event. Michael Gove would do well to reflect that not long ago Bovine Spongioform Encephalopathy resulted in the slaughter of 4.4 million cows in the UK and was responsible for variant Creutzfeldt-Jakob disease in humans. The World Health Organisation has warned against use of the term ‘Chinese virus’ saying that it could lead to racial profiling against Asians when “there is no blame in this”. In the UK we have already seen reports of Asian people being physically attacked in the street.
Writing in the nineteenth century in his book The Housing Question, Frederick Engels made a highly relevant comment on the self-interest that motivates those who are in control of society through virtue of their wealth and position. “Capitalist rule cannot allow itself the pleasure of creating epidemic diseases among the working class with impunity; the consequences fall back on it and the angel of death rages in its ranks as ruthlessly as in the ranks of the workers.”
Having said that, the competence of the ruling elite in preventing and controlling epidemics is always in doubt, since their desire for profit is in opposition to any inclination to spend money on public services until it is too late. Thus an opportunity to avert a crisis is lost, and a pandemic that could have been limited if planning advice had been implemented and intervention had been timely must instead run its miserable course. We have known for the past 13 years, for example, that a pandemic at least as lethal as coronavirus represented an ever present major threat.
At the same time we can be sure that history will be busily rewritten in order to exculpate ministers and make sure any temporary steps towards ‘nationalisation’ of services are quickly reversed. There may even be calls to continue the restrictions on civil liberty for much longer than the medical situation necessitates.
Charles Moore (former editor of the Daily Telegraph, where he was Boris Johnson’s exasperated boss) is jockeying for position in this vanguard, explaining to readers that it is in fact deficiencies in the public sector that has brought the country to lockdown. In a sense Moore is correct, but for the wrong reasons. It is the underfunding and weakening of the NHS at the hands of the Tories that has made it much less able to deal with the current crisis, making lockdown even more crucial in order to limit demand. We can also expect to hear from other ideologues about how our small and parasitic private sector came to the rescue of the NHS in its time of need.
However much the Tories are now clapping for our NHS, we must remember that they are fundamentally opposed to public services, and will soon forget their panic and revert to form. A former Tory insider, now disillusioned with the world view that anything funded by the state is wrong (except of course infrastructure that furthers the interests of the rich), has written a tell-all piece stating as much.
Our job as health campaigners is to now make sure the right lessons are learned during the coming weeks and months. We need to keep the Tories on the hook, and harness the public anger which will no doubt grow over time. We must rally the vast majority of society around our vision of a health and social care service that exemplifies a more just, equal and caring society.
Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.
Given the chronic underfunding of the NHS, it is no surprise that rationing appeals to commissioners as a way of limiting expenditure. However, this goes against the NHS Constitution, which establishes that “the NHS provides a comprehensive service, available to all” and “access to NHS services is based on clinical need, not an individual’s ability to pay”. It is therefore approached in a covert manner.
The most obvious form of rationing is the waiting list: between March 2013 and November 2018, the number of people still waiting for their treatment grew from 2.7 million to 4.2 million, and the number waiting more than 18 weeks grew from 153,000 to 528,000. Exceptional funding requests, originally used to limit cosmetic and fertility treatment, have expanded into areas including hip and knee surgery as Clinical Commissioning Groups seek to limit patient access. Bristol, North Somerset and Gloucestershire CCG now lists 104 restricted treatments. GPs are no longer able to decide when a patient should be referred for a consultant opinion. In many situations, rationing has been disguised as “addressing unwarranted variation”, “evidence based medicine”, and even “patient choice”.
Simon Stevens, The World Economic Forum, and McKinsey
A 2012 report from the World Economic Forum (based on work led by Simon Stevens, then head of United Health’s Global Division and now Chief Executive of NHS England) focused on economically challenged health care systems and how to “help existing models become sustainable”. One proposal was to “ration access to care… for example, restricting coverage, imposing cash-limited budgets and allowing waiting lists to rise, or reducing the scope of services covered”. The Five Year Forward View of October 2014 which Sustainability and Transformation Partnerships are now set to implement is drawn directly from the WEF’s diagnosis of, and prescription for, the healthcare crisis.
The WEF report was produced in association with management consultancy firm McKinsey, who in 2009 advised the Department of Health on “how commissioners might achieve world class NHS productivity”. Their presentation outlined the potential for savings by decommissioning procedures of “limited clinical benefit”. These included tonsillectomy, back pain, grommets, trigger finger, Dupuytren’s contracture, knee washouts, dilatation & curettage, minor skin surgery, aesthetic surgery of various types, knee surgery, hip surgery, and cataract removal. Nearly all of these procedures are to be found in the Croydon list, NHS England’s 17 Evidence Based Interventions, and the shopping lists of self funding NHS patients.
The obsession with unwarranted variation
Even before McKinsey’s work, in 2007 the London Health Observatory explored the potential savings that might be realised if treatment access criteria could be standardised for certain procedures – the Croydon list. This focus on variation has been continued under the strapline of getting it right first time, or GIRFT, “designed to improve the quality of care within the NHS by reducing unwarranted variations… as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings”. NHS RightCare is also concerned with variation in outcomes between CCGs. RightCare has been implicated in unjustified proposals to cut hip and knee replacement surgery, and its methodology has been strongly criticised. The vey real difficulties of measuring “unwarranted variation” are discussed by the King’s Fund. Their report contains a pertinent quote from Professor Al Mulley, Managing Director for Global Health Care Delivery Science at The Dartmouth Institute for Health Policy and Clinical Practice:
“If all variation were bad, solutions would be easy. The difficulty is in reducing the bad variation, which reflects the limits of professional knowledge and failures in its application, while preserving the good variation that makes care patient centred. When we fail, we provide services to patients who don’t need or wouldn’t choose them while we withhold the same services from people who do or would”.
17 Evidence Based Interventions
Variation was also central to the 2018 NHS England consultation and subsequent recommendations to commissioners, 17 Evidence Based Interventions. This identified four generally unwarranted procedures that should almost never be done, and 13 warranted procedures where considerable reduction in activity was anticipated through standardising access criteria. The 13 procedures are breast reduction, removal of benign skin lesions, grommets for glue ear in children, tonsillectomy, haemorrhoid surgery, hysterectomy, chalazia removal, arthroscopic shoulder decompression, carpal tunnel syndrome release, Dupuytren’s contracture release, ganglion excision, trigger finger release and varicose vein surgery.
Where there were already existing NICE guidelines, NHS England recommendations generally conformed with them. But where there was no NICE guidance, NHS England is generally restrictive (regarding skin lesions, breast reduction surgery and ganglion removal). It seems likely that CCGs and referring GPs will consider many of these treatments as to some extent off limits, making it more difficult for patients (including those who actually meet NHS England criteria) to access treatments. While arguably the four “unwarranted” procedures are of little clinical benefit, restricting the other 13 is likely to deprive some patients of valuable interventions.
NHS England argued that the main cause for variation was doctors failing to observe accepted evidence based guidelines, despite the absence of such guidance for some of the procedures. Consequently, it was necessary to introduce economic levers to force providers to reduce activity by threat of non-payment for work done. The title of the consultation was meant to convey the impression that a rigorous review of relevant evidence underlies the recommendations. However, the methodology used is not transparent (unlike NICE) and does not conform with accepted standards for guideline development. It seems more likely that the authors started by drawing conclusions, and then sought supporting evidence from a selective review of the literature. Although both relevant Royal Colleges and NICE were consulted (and appear on the front of the consultation document), they distance themselves from the recommendations made (with the exception of the uncritical Academy of Medical Royal Colleges). NICE explained that “this work was undertaken by NHS England rather than NICE. It would be inappropriate for us to comment on the validity of this work and the subsequent published guidance”.
What underlies variation?
A large component of variation among providers for the 17 interventions relates to treatment access policies, devised by Primary Care Trusts and then CCGs, which are increasingly at odds with NICE guidance. This is not acknowledged by NHS England, yet it becomes obvious on accessing their own website. For example, when searching NHS England for breast reduction surgery we find the following statement: “some CCGs do not fund breast reduction surgery at all, and others fund it selectively if you fulfil certain criteria”. If the evidence based criteria for treatment access from the 17 interventions consultation process were strictly imposed, while projected activity in some CCG would fall, in others it would have to rise. It is striking that in the tables published by NHS England estimating the possible effect of the recommendations, nowhere is there an increase in activity. This exposes the sham of these recommendations – they are neither national, nor evidence based.
17 Evidence Based Interventions introduces a mindset in which the public accepts that it is justifiable for some treatments (currently those seen as largely cosmetic, and therefore a soft touch) to no longer be provided by the NHS. NHS England promises that many more procedures will be added to the list in due course. As there is no intention on the part of NHS England to advise CCGs to follow national guidance and commission services where they currently do not, this source of variation is not effectively addressed. The website Ration Watch shows that many CCGs are already routinely restricting access to treatments including hip and knee replacement, hernia repair, and cataract removal, and are simply ignoring NICE guidance.
NHS Clinical Commissioners, the national body representing CCGs, describes this state of affairs as a regrettable but often unavoidable consequence of the systemic financial pressures on the health service, confirming that financial concerns are the underlying driving force for such forms of rationing. Further undermining of the force of NHS England guidance is the fact that many restricted treatments are being made available to NHS patients at a price – the so called self funding patient.
Simply using the term ‘evidence based’ does not legitimise a policy unless the methodology underlying recommendations is both transparent and scientifically robust. It should then be left to doctors to implement guidance after taking into account the individual needs and preferences of a patient (the real essence of evidence based medicine), rather than them being forced to follow a course of action imposed through economic sanctions. As NICE always states: “When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service”. It is ironic that NHS England pays lip service to a “new national ambition to embed personalised care across England so that shared decision making between patients and clinicians becomes the norm”.
Variation in the NHS is a topic deserving of scientific scrutiny, but as the King’s Fund points out, the patient must remain at the centre. “A key focus will need to be to tackle clinical decisions… with patients as a way of driving out unwarranted, and promoting warranted, variation”. Some treatment access policies are now being written for CCGs by shadowy Clinical Commissioning Support Units. CCGs should be openly challenged on how such policies have been developed and in whose interests they operate. They must be asked to justify their rejection of NICE guidance where this exists. The claim of being evidence based requires scrutiny, and may well prove unfounded when examined carefully.
Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.A longer version of this article was presented at a Doctors in Unite meeting in September 2019.