A Trojan Horse? Keep Our NHS Public examine the government's Integrated care proposals

The case for Integrated Care seems obvious - who could be against integration it if improves the care of citizens? Keep Our NHS Public look beyond the initial favourable reception of the proposals and examine the prospect of them opening up the potential for more private involvement in the NHS LINK

FROM KEEP OUR NHS PUBLIC

In the middle of the Covid pandemic, when the NHS and its staff are going flat out to cope, NHS England (NHSE) is stealthily transforming the NHS again. What is portrayed as an innocuous move to ‘integrate’ care and reduce bureaucracy will, in effect, move decision-making even further from local communities and increase the presence and influence of the private sector in the NHS.

At the moment, the main tools for this transformation are Integrated Care Systems (ICSs), supported by plans for new legislative powers.  Although ICSs are already in place in some parts of England, a new document from NHSE provides the clearest glimpse so far of what ICSs could mean.

The proposals, recently echoed in a government White Paper, are of huge concern. Although seen by the media as suggesting the role of the private sector will be reduced, the proposed legislation, if passed, will enact the current government’s wish to further fragment, destabilise and privatise our NHS.

Background

Regulations brought in by the Health and Social Care Act (HSCA) of 2012 enforced a new competitive ‘market’ within the NHS.  The Act also introduced Clinical Commissioning Groups (CCGs) that were required to put clinical and other services out to competitive tender and so allowed increased private company involvement in the NHS.

Since then, while still retaining the market system, NHSE has declared that competition is to be replaced by the “integration” of NHS, local authority and other service providers. NHSE’s ‘integration’ has involved fragmenting the NHS into 44 areas (originally called ‘Sustainability and Transformation Plans’) destined to eventually morph into 42 Integrated Care Systems. The NHS Long Term Plan requires every NHS organisation and their local ‘partners’ to become part of an ICS by April of this year.

What are ICSs?

According to NHSE, ICSs are bodies in which

“NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve.”

The ‘others’ they refer to include private companies. An ICS will have a ‘single pot’ budget and its partners will collectively decide how to delegate that budget to loosely defined local “places” within the ICS.

Legislative change

The powers of ICSs are currently under review. NHSE argues that existing law, such as the HSCA (2012), does not provide a sufficiently firm foundation for the work of ICSs, so they propose scrapping Section 75 of the Act, which, for example, requires commissioners to put any contract worth over £.615,278 out to tender. They have also sought views on two options for enshrining ICSs in legislation.

Both options provide an ICS Board and a single ICS Accountable Officer. In one option, there would be a single Clinical Commissioning Group (CCG), along with a new duty for providers, such as NHS Trusts, to comply with the ICS plan. In the second option, NHSE’s preference, CCGs would be ‘repurposed’, whatever that means, and their commissioning functions transferred to the ICS Board. While the veto of individual organisations within the ICS would be removed, the ICS could delegate responsibility for arranging some services to providers “to create much greater scope for provider collaboration”.

What are the main issues for campaigners?

ICSs raise multiple issues but we focus on three main areas: the increased potential they offer for private companies to profiteer from the NHS; the unequal partnership they create with local authorities and the subsequent threat to social care and public health services; and the loss of accountability.

• Increased scope for private companies

Removing Section 75 of the HSCA (2012), by itself, won’t reverse the marketisation of the NHS. Worse still, it would involve revoking Procurement, Patient Choice and Competition Regulations, so turning the NHS into an unregulated market.

The proposals also recommend that NHS services be removed from the scope of the Public Contracts Regulations 2015, allowing commissioners more discretion when procuring services. It means that ICSs would be able to choose whether to award a contract directly to a provider or go through a more formal procurement process. Such flexibility massively increases opportunities for cronyism, as shown during the Covid pandemic when emergency measures allowed the usual procurement rules to be bypassed.  For example, the National Audit Office found that during the early stages of the Covid crisis, companies with ‘connections’ (for instance with government officials, MPs, or senior NHS staff), were ten times more likely to be awarded a contract than those without such links – even if they were entirely unsuitable suppliers.

The possibility that ICSs, operating in a market system, can chose to dispense with formal procurement processes is additionally alarming as NHSE wants to give each ICS a free hand in appointing its governing Board. This means that these Boards could include representatives from private providers – a move that’s described as “a blatant undermining of the ICS as an NHS body”.

The way that ICSs are to be internally managed will also increase privatisation. NHSE has accredited 83 companies to provide support for developing and managing ICSs through what’s known as the Health Systems Support Framework (HSSF). In the words of NHSE,

“The Health Systems Support (HSS) Framework provides a quick and easy route to access support services from innovative third party suppliers at the leading edge of health and care system reform”.

These companies, as you might guess, include McKinsey, Deloitte, Optum, IBM, Ernst and Young, Centene, and other global corporations, along with some UK and European companies, and a handful of NHS Commissioning Support Units.

The HSSF is divided into 10 ‘Lots’ covering services such as patient record systems, transformation and change support, capacity planning support, patient empowerment, and digital tools to support system planning. As NHSE points out,

“The Framework focuses particularly on services that can support the move to integrated models of care based on intelligence-led population health management. This includes new digital and technological advances that help clinicians and managers understand a population’s health and how it can best be managed.” (Our emphasis)

Population health management (PHM) is described by NHSE as “an approach aimed at improving the health of an entire population and improves population health by data driven planning and delivery of care to achieve maximum impact for the population.”

Briefly, PHM (“the critical building block for integrated care systems”) relies heavily on the mass collection and analysis of data from across multiple care settings, and a shift from care provided by clinicians face-to-face, to much more digitally provided care via remote consultations and algorithms. This inevitably means more private sector involvement due to the capital investment required for digital infrastructure, not to mention increased access to patient data for tech companies.

In addition, PHM shifts the focus of the NHS from delivering universal comprehensive care to individuals towards achieving data targets for the population covered by the ICS. Depending of course on how, and by whom, and with what aim, those data targets are set, what’s “good” for the population may be at odds with the needs of an individual.

• The threat to social care and public health services

ICSs are an essential part of a shift towards a ‘place-based approach’ to health and social care, with ‘place’ often seen as coterminous with local authority (LA) boundaries. According to the NHS Confederation, this level of working is the right scale for tackling ‘population health challenges’, such as health inequalities. A ‘place based approach’ is also part of a shift towards PHM, as well as shared responsibility for resources and service changes across all public services within the area.

NHSE proposals suggest that ICSs become the means for more ‘integration’ between the NHS and LAs. However, in its response to NHSE’s proposals, the Local Government Association (the national voice for local government) raises concerns that ICSs won’t be a partnership of equals across the broader health, wellbeing, and social care system. Instead, ICSs will be NHS-led, allowing a power grab that brings LA resources such as capital assets and funding for social care and public health under ICS (and thus NHS) control. There is also a risk that power won’t be devolved to local systems. Rather, central control will remain, with missed opportunities for real collaboration between the NHS and LAs to address the wider determinants of health, such as affordable housing and a safe environment.

Further, KONP among others has highlighted the risks posed by NHS management of social care. Social care is not an adjunct of the NHS, but has a very wide remit that overlaps with wider local authority responsibilities including housing, leisure, planning and education. In addition, social care is means tested while NHS care is (largely) free at the point of use and funded by taxation. If ICSs take on social care, they will have to develop complicated charging mechanisms. This could pave the way to charges for NHS services or, long term, for the introduction of a private insurance-based system (facilitated, incidentally, by the extensive data sets created by PHM). NHSE’s proposals also fail to mention any safeguards to prevent services that are currently free from being redefined as social care and so subject to means testing.

• Loss of accountability

 In contrast to local authorities, ICSs are not subject to democratic control. NHSE’s proposals will give them the power to create publicly unaccountable joint committees, potentially including representatives from private business, to make legally binding decisions about major resource allocation and service provision.  (For KONP’s vision for achieving democratic accountability, see here.)

CCGs, with their responsibility to manage local budgets, will be weakened or, as NHSE would prefer, abolished. In the absence of any plans to make ICSs accountable to local residents or patients, it seems that people over large areas of England will be disenfranchised. Although ICS Boards will supplant existing public bodies, there appears to be no requirement for them to meet in public, publish their Board papers and minutes, be subject to the Freedom of Information Act, or to have any democratic participation from the communities they cover.

What can we do?

KONP calls for a halt to the development of ICSs until there is a full consultation with the public, local authorities and Parliament. It argues that not just Section 75 but the entire Health and Social Care Act (2012) should be repealed and the NHS Reinstatement Bill laid before Parliament. This proposes restoring the NHS as an accountable public service; ending contracting and the purchaser-provider split; and re-establishing public bodies and public accountability to local communities.

We call on Councillors and MPs to be briefed in detail on the issues before legislation is tabled, and to be ready to challenge it.

We call on activists to make these issues a campaign focus, before legislation is tabled.

Big changes ahead for cash-strapped Brent Clinical Commissioning Group

Brent Clinical Commissioning Group (Brent CCG) which has an £11.2   deficit, is to move from Wembley Centre for Health and Care in Chaplin Road, Wembley to the Brent Civic Centre. In turn the social work team will be moved from the Civic Centre to the Willesden Centre for Health and Care.

Other nearby Clinical Commissioning Groups are also in deficit and so they, along with Brent will be moved into a ‘super’ CCG covering the whole of North West London to save costs.

The way each proposal interacts with the other is as yet not entirely clear. 

The Brent CCG move to the Civic Centre is premised both on saving money and improving working conditions and there is an additional justification based on the benefit  joint work with Brent council departments, although it is not clear why that does not also apply to the social work team.

One key element is the role of NHS Property Services (NHS PS). As covered previously on Wembley Matters as part of the gradual marketisation of the NHS they seek market rates for their properties and charge for ‘void’ (unused) spaces. Brent CCG will save on these charges but there is a risk that NHS PS will not accept the ‘hand back’ of the current space they occupy.

The Brent CCG is required to adopt the North West London ‘Agile Working Policy’ which doesn’t mean that they combine office work with yoga - it just means that they have no fixed personal desk and that there are more staff than there are seats available. I guess the agility comes in when they all leap over each other to try and bag a seat in the morning:

In addition to the rent  for accommodation on the 5^th and 6^th floor of the Civic Centre Brent CCG will have to pay Brent Council an additional, discounted, charge for use of the Boardrooms and Conference Hall. Staff will have to pay to park their cars at the Civic Centre if they wish to drive to work.

The rent paid by Brent CCG to Brent Council will be £299,000 annually, Brent Council will pay £180,000 annually for the Willesden Centre, but this will be reduced to £80,000 over the 10 year lease period because Brent will have to spend £800,000 to ‘kit out’ Willesden because at present it is a ‘shell.’

While all this is going on the move towards a single CCG to cover North West London has accelerated. This extract from yesterday’s Health and Wellbeing Board explains:

Single CCG Across North West London 

1.     The 10 Year Plan requires that there will be a shift to a CCG for every ICS area – in Brent’s case this would be a North West London CCG. This would mean a consolidation of existing CCGs, which will become leaner, more strategic organisations that support providers to partner with local government and other community organisations on population health, service redesign and long-term plan implementation. 

2.     The movement towards a single CCG may take place either via changes to the constitutions of the 8 individual CCGs in North West London or via a formal merger application to NHS England. In the latter scenario this would mean that Brent CCG would cease to exist as a legal entity and that commissioning responsibilities would be merged into a new organisation – North West London CCG. 

3.     A working group has been set up at North West London level to design the structure of the single CCG. Since North West London collaboration is currently in a significant deficit position, the movement towards a single CCG is being accelerated in order to achieve administration cost savings. Current plans are to finalise the new structure by the end of April 2019 and to approve a case for change in May 2019, with staff consultation progressing in June 2019. The plan is to have completed the move to a single CCG structure by April 2020. At the time of writing, it is anticipated that there will be a local ‘branch’ of the CCG that will be based locally within the borough. This local arm will be focused primarily upon primary and community care, and the development of the local ICP.

Will this mean that the super CCG will take up the accommodation at the Civic Centre or will it be allocated to a 'local branch'? 

What will be the extent of redundancies across the eight CCGs and how will those in the 'top jobs' be affected? 

What independent powers will a 'local branch' have?

How will both the 'super CCG' and the 'local branch; be democratically accountable to local residents?

Meanwhile a small but vital organisation, Brent Advocacy Concern, that has served disabled Brent residents for 30 years, have been caught up  in the new market rents policy and will have to find £16,000 in December for the annual payment for their space in the  Willesden Centre. A sum that they cannot afford and so they are faced with finding a cheaper alternative or closing down...

Brent's child obesity crisis worsens - nearly 1 in 3 obese on leaving primary school

A report to the Brent Community Wellbeing Scrutiny Committee lays out the stark facts. Graphs show the annual trend since 2013 (click on images to enlarge):

The most significant trend is the proportion of Year 6 children who are obese as they make the transition to secondary school. The figures are well above the London and England averages and the latest figure at 28.6% compares with 24.63% in 2013.

4 and 5 year olds in Reception classes have a lower level of overweight and obese children but there the proportion of overweight children has peaked at 14.8% (13.06% in 2013) and the proportion of obese children is almost back to 2013 levels at 13.8% (13.97%) despite a dip in the interim.

The report looks at the relationship between deprivation and obesity and found only a weak link in ward data:

Analysis by ethnic group shows the highest overweight and obese group is the Black group but the Asian increase in obesity rates from Reception to Year 6 is also worth noting.

The report LINK lists initiatives already underway to tackle the problem including promotion of breast feeding, adoption of Maternity Early Childhood Sustained Home Visiting model, the Healthy Early Years Award introduced in 2012, Health Schools London award, Action on Sugar (includes sugar free Tuesdays), Allotment and Food growing Strategy, promotion of physical activity and action on takeaways near schools.

All this hasn't reduced child obesity although there is a slight reduction for 2016-17 in Year 6 overweight children. Clearly more needs to be done to tackle what is an urgent public health issue.

The report outlines what is proposed by the Brent Clinical Commissioning Group:

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The proposed Service Delivery Improvement Plan would be:

1)  Review food provided by the Trust in line with guidance on reducing obesity 
and health weight by end of Quarter 1 (30 Jun 2018); 


2)  Develop a local action plan to promote healthier options by end of Quarter 2 
(30 Sep’18), and monitor in Quarter 3 (Oct-Dec 2018) and Quarter 4 (Jan-Mar 
2019); 


3)  Develop a plan for front-line staff to have ‘Make Every Contact Count’ training 
about reducing childhood obesity and local weight management services by end of Quarter 2 (30 Sep 2018), and monitor in Q4 (Jan-Mar 2019); 


         4) Identify conditions where obesity is a risk factor (e.g.CHD, dementia,  diabetes), ensure family members are aware of ways to reduce their risks by being healthy weight, and ensure the family knows how to access weight management support, in Q3 (1 Oct 2018) onwards.

The treatment of childhood obesity

 The new 0-19 children’s public health service includes tier 1 and 2 weight management service. This is a preventive universal service with additional lifestyle weight management services for those children, and their families, who are overweight or obese. This is a new service within health visiting and school nursing and mobilisation has been delayed by difficulties recruiting to the new team. However, the full establishment has now been appointed. 


The CCG commissions tier 3 services for those children who require specialist paediatrician or dietician clinical assessment and advice. A very small number of children will require drug treatment or surgery. 


 The CCG and public heath secured funding from Health Education England which was used to provide tier 1 weight management training to front line staff working with children in Brent. 173 people have attended this training which should ensure a consistent high quality offer across the Borough. 


Imperial CEO Ian Dalton resigns to go to NHS Improvment with NW London NHS in turmoil

Sir Richard Sykes, Chairman of Imperial College Healthcare Trust, shocked those attending the Imperial Board meeting yesterday when he announced that CEO, Ian Dalton, was leaving his post after less than 5 months in the job. Imperial, which runs west London hospitals, will now have to begin the long and costly process of finding yet another CEO.

Ian Dalton has now moved to NHS Improvement as their new CEO. NHSI is the body that, only last month, knocked back capital investment plans to reconfigure health delivery in outer NW London on the grounds that there was not sufficient evidence that these plans would work. This was the initial bid for capital funds to develop services which, local health bosses claim, would enable the safe closure of Ealing Hospital.

Dalton’s resignation followed almost immediately the well-attended and highly successful open event organised by Imperial management at Charing Cross Hospital. At that event Dalton outlined the excellent work being carried out at the hospital and gave an assurance that Charing Cross could not be closed in the foreseeable future without damaging public health. However, long-term closure plans have not been withdrawn by the CCGs in NW London: what we have is a ‘pause’, not a guarantee of the long-term future of Charing Cross as a major acute hospital.

The resignation occurs at a time of particular turbulence in upper management levels of the NW London NHS. Several key managers have left in recent months and other posts remain unfilled. Managers are caught between a government demand to cut costs even further and, among health professionals, a recognition of the growing need for better funded health services for a fast expanding population.

Merril Hammer, Chair of SOH, said she was stunned by the sudden departure of Ian Dalton. At the Imperial AGM held at St Pauls Church Hammersmith in September, he had outlined ambitious plans for engaging with the local health community.

Ms Hammer said:

I am, of course, pleased that Imperial has now declared a ‘pause’ on the closure but given the unprecedented pressure on the facilities at Charing Cross and the highly skilled committed staff there, health bosses need to stop long-term closure plans and not just ‘pause’ them.

How effective was Brent Scrutiny's consideration of the STP?

The Sustainability and Transformation Plans for the NHS have come in for severe criticism as a cover for cuts.  The Brent Community and Wellbeing Scrutiny Committee of September 20th discussed the plans.  This is the official minute of their discussion:

The committee considered the report from the Chief Executive of Brent Council and Chief Officer of Brent Clinical Commissioning Group on the Sustainability and Transformation Plan (STP). Rob Larkman (Chief Officer, Brent Harrow Hillingdon CCGs) advised that the requirement for the production of the STP was introduced by the NHS England in 2015. The purpose of the STP was to help local organisations plan how to deliver a better health service by addressing three key areas; improving health and wellbeing, improving quality of care and tackling the financial gap. The STP moved away from an organisation by organisation view to establish a broader strategic approach. Brent fell under the STP for North West London. It was acknowledged that work for this was taking place at several levels. At the North West London Level work was underway to draw together the place- based planning taking place in Brent and the seven other North West London Boroughs which were encompassed by the North West London STP. The STP was required to be submitted by the end of October 2016. It was emphasised that the timescales set out for the creation of the STP were extremely challenging. A draft NWL STP had been published and it was now necessary for all the statutory bodies affected by the STP to consider the details in line with their respective governance arrangements.

Addressing concerns regarding transparency and accountability, Carolyn Downs (Chief Executive of Brent Council) explained that the task of creating high quality plans to the level of detail required within the timescales set out had been extremely challenging. However, the NWL STP was recognised as one of the more detailed plans created and was the only one in the country for which joint governance processes had been supported to ensure political input from all affected local authorities. Reflecting this, five of the eight local authorities had jointly commissioned work to test the assumptions in the plan specifically related to the cost of additional out of hospital care to social care as a result of any proposed changes to acute services. The NWL STP was the only plan in the country to specifically address the social care funding gap. The NWL STP was also one of only two plans to have been published and a series of public engagement events would be held. Councillor Hirani (Cabinet member Community Wellbeing) added that events would be held out in the community in places such as supermarkets, stations and high streets to inform and engage residents.

Sarah Mansuralli (Chief Operating Officer, Brent Clinical Commissioning Group) outlined the work taking place at a local level. Members heard that a STP Brent- level working group had been established bringing together statutory partners including the Acute Trust, the Central and North West London Mental Health Trust and Brent Healthwatch, to break down organisational barriers. The working group had sought to identify the initiatives that would have the highest impact in Brent for addressing the three key issues at which the STP was targeted. Phil Porter (Strategic Director, Community and Wellbeing) detailed the five areas which had been identified as part of this work noting that this included prevention and self- care, renewing the ambition and focus in Brent’s Better Care Fund schemes, using the OnePublic estate model, ensuring mental health and wellbeing had equal focus with physical health and wellbeing and, underpinning all the rest, integrated workforce and organisational development.

At the invitation of the Chair, Simon Crawford (Director of Strategy, London North West Healthcare NHS Trust) emphasised that the STP provided a vehicle for collaborative working on the out of hospital agenda and integration and Brent was one of the most advanced in identifying what this meant locally. Julie Pal (Healthwatch Brent) expressed her confidence in the process being followed in Brent, having experience of delivering across a number of STP areas and noted that Brent residents’ voices were clearly contributing to the shaping of the transformation agenda.

Members questioned the extent to which Brent had been able to influence the setting of local priorities within the STP. A Member emphasised that housing was integral to the safety and security of those with Mental Health issues but that taking up employment could create a significant barrier for accessing appropriately supported housing. In view of this and with reference to plans to develop a multi- disciplinary team with a remit for mental health, employment and housing it was questioned what would be done to address this issue and ensure necessary support was provided. Further details were sought regarding the planned engagement activity and how this had been advertised. It was suggested that local pharmacists be approached within this engagement work in recognition of the level of contact that they had with people and similarly, that consideration be given to involving other local organisations and bodies including voluntary organisations and the patients forum. Questions were raised regarding extending access to GPs and investment in the Central Middlesex and Willesden sites. Addressing the tight timescales involved, the committee queried whether this posed any risks in terms of gaps in delivery.

Rob Larkman and Sarah Mansuralli confirmed that the borough had absolute discretion in determining the priorities for Brent. Local priorities had been established with reference to the Joint Strategic Needs Assessment and had then been consolidated at the NWL level. Similar processes had been followed by other NWL authorities. Phil Porter acknowledged the significant challenge posed by housing and employment issues for those with mental health needs and noted that a dedicated housing officer was now in place and work was underway to build a network of private sector landlords willing to offer secure tenancies. Carolyn Downs welcomed the insight provided by members into this area. It was suggested that the committee consider at a future meeting the West London Alliance Mental Health and Employment Integration National Trailblazer which aimed to bring together GPs and wider organisations to support people into employment.

Addressing queries regarding the community engagement activity, Councillor Hirani emphasised that public meetings would be held alongside a series of events at public locations. Members of the public would be invited to share their views in a variety of ways. Work was also currently being carried out to allow residents accessing acute and hospital services to feed their views into the process. Sarah Mansuralli welcomed members suggestions regarding approaching pharmacists and other groups including patients’ forums and confirmed that these would be taken forward. A Health Partner Forum was scheduled for 19 October at which the CCG commissioning intentions (based on the STP) would be discussed. Members were further advised that an online engagement tool had been launched for the whole of North West London and had been widely circulated.

Rob Larkman confirmed that extending access to GPs was a crucial element of the STP and now that co-commissioning arrangements were in place between NHSE and CCGs, greater influence could be exerted. Addressing queries about investment in the Central Middlesex Hospital and the Willesden Hospital sites, Sarah Mansuralli explained that the intention was to fully utilise each site for out of hospital provision. The demography of the area around the Central Middlesex Hospital was changing and consideration was being given to how best to organise service provision accordingly. Carolyn Downs emphasised that the work on the STP would remain an alliterative process and the flow of investment, savings made and outcomes achieved would need to be constantly reviewed.

RESOLVED:

.        (i)  that the officers and colleagues present be thanked for contributing to the detailed and open discussion held; 


.        (ii)  that the committee welcomed the work being undertaken to ensure that issues regarding transparency and accountability were highlighted as part of the process of creating the Sustainability and Transformation Plan; 


.        (iii)  that an update be provided to the committee on the OnePublic Estate, including an update on the Central Middlesex and Willesden Hubs; 


.        (iv)  that efforts be made to engage with Health Scrutiny across North West London with regard to the Sustainability and Transformation Plan; 


.        (v)  that consideration be given to collaborative work with Healthwatch groups to support engagement around the Sustainability and Transformation Plan 


.        (vi)  that a regular progress report on the Sustainability and Transformation Plan be provided to the committee, the first of these to be provided six months from the date of the current meeting.