On 11 June 2018 the Common’s Health and Social Care Committee published the result of their inquiry into Integrated Care: organisations, partnerships and systems.
Anyone who observes Sarah Wollaston will notice that from time to time she confounds expectations and raises concerns about what her party is doing in government, notably on her strongly worded letters to the Home Office on the treatment of immigrants within the NHS. Although her voting record shows a reluctance to translate strong statements into protest in the division lobby. There was, therefore, a glimmer of hope over her chairing of the committee when she insisted to Jeremy Hunt that the ACO process should be subject to full and proper consultation – to ensure that it complies with the law.
During the long process of privatising the NHS, there have been moments when the tide could have turned or at least the process could have been exposed to proper evaluation. The greatest and possibly the most disappointing of these moments was the pause before the implementation of the Health and Social Care Act 2012.
Could Sarah Wollaston’s committee have provided one of these moments? Possibly, but it didn’t. It has failed on every count.
- It was framed to deceive
The report summary says, ‘Whilst there is not sufficient evidence that integrated care saves money or improves outcomes in the short term, there are other compelling reasons to believe it is worthwhile.‘, ‘There have been positive early signs from the new care models about the benefits more integrated health and care services can bring to patients.‘
It goes on, ‘understanding of these changes has been hampered by poor communication …confusing acronym… poorly understood… fuelled a climate of suspicion… and missed opportunities to build goodwill for the co-design of local systems that work more effectively in the best interests of those who depend on services.‘
The summary sets out the terms of reference for the report. It suggests to the reader that what is in the body of the document is compelling evidence. It states that there are positive benefits from the system they have examined. And finally, it implies a dismissal of the concerns of campaigners on the basis that they are ill founded. It makes clear that such opposition can only arise from misunderstanding and the cumulative effect of those misunderstandings has been harm to patient care which a proper implementation would have had high on its own agenda.
- It had a discriminatory attitude to its participants
There were two Professors of note in the Inquiry whose qualifications and expertise should have given them considerable weight, coming as they did from opposite sides of the divide on this issue.
Professor Chris Ham (along with his colleague Anna Charles) of The King’s Fund was a specialist advisor to the inquiry and the report declares his interests, ‘The King’s Fund is working to support Accountable Care Systems in England and some of the money for this work has been provided by NHS England’.
Chris Ham advised both New Labour and the Tories on Integrated Care. When New Labour ran its NHS Kaiser Beacon projects in 2003 he had a dual role both as advisor to the health department and academic assessor of the outcomes of the project. He is now the CEO of The King’s Fund. The Fund promotes Kaiser Permanente and its work as a role model for integrated care. He was also a key witness to the committee. Chris Ham was awarded a CBE in the June 2018 Birthday Honours List for services to the NHS.
Professor Allyson Pollock is the co-author of the NHS Reinstatement Bill and one of the claimants in the judicial review JR4NHS. She has been a consultant in Public Health medicine since 1986, has headed up Public Health Policy units at various prestigious universities and has served on the council of the British Medical Association. Her early work analysing the Private Finance Initiative exposed many of the flaws in the process which have since been accepted as standard. Her work lies in the realm of protecting the NHS as a public service.
When Simon Stevens gave his oral evidence, he was asked by committee member Luciana Berger about the risk of increasing privatisation in the NHS. He had prepared a response which included printed out articles by Allyson Pollock. Rather than addressing the current situation and any implications there might be for privatisation he simply chose to attack Allyson Pollock’s work personally. He refers to an article on Privatisation and Americanisation in the NHS. He uses the fact that Allyson has been writing continuously and has been monitoring the incremental steps towards privatisation as evidence that she is wrong.
He subsequently says, “It is absolutely crucial that NHS care remains free and based on the needs of patients rather than ability to pay. There is nothing that has been proposed about the ability to join up the way health and social care services work that was not established by Parliament as far back as 2006, and in other places that has been working perfectly satisfactorily.”
He goes so far as to say, “If Nye Bevan were sitting here now, I think he would be a strong advocate for the kind of integrated care systems and combined funding streams we are talking about.”
Whether or not the service is currently or historically working satisfactorily is not a rebuttal of whether or not it is being privatised. However, the report includes in section 40 a warning against removing choice and competition, ‘there is a danger of creating airless rooms in which you simply have one provider who is there for a huge amount of time.‘ That clause is a statement against the basic principle of a publicly owned, publicly provided and publicly managed NHS.
One member of the committee Andrew Selous MP spoke at the 23 April debate in Westminster Hall on privatisation. In the oral evidence session with Simon Stevens Andrew Selous asked the first question which was, “If we can have in our minds a lady in her mid‑80s, with a number of long‑term conditions, perhaps living on her own with her family around the country, could you explain as clearly as you can how the changes you are making will improve care for this elderly lady in her mid‑80s living on her own?” This reference is to ‘Mrs Smith’, a fictional character used by Chris Ham in his analysis of the Torbay NHS Kaiser Permanente Beacon project.
In the privatisation debate Andrew Selous praised Chris Ham as an independent expert on the NHS. By contrast he referred to Allyson Pollock as well-meaning but misguided and used Simon Stevens’ attack on her as evidence of her lack of credibility. It’s a distinction which is woven through the report and embedded in the framing: the supportive and friendly witness is, by definition, independent, authoritative, expert; the critics, on the other hand, know not of what they speak, are misguided and misinformed. What concerns they have is portrayed as the result of poor information management and a mistaken attempt on behalf of NHS England and the STP leaders to keep plans out of the public domain until they are completed.
There is a high-level of cognitive dissonance over this issue as the report fails to infer from the secrecy, leaks and cuts that there is a sound and rational basis for concern. For example, they accept [Section 60], ‘In the run up to the final deadline coverage about the secrecy of plans continued and was accompanied by reports of plans were leaked to the press, in which the focus of the coverage was on proposals to close services, reduce bed capacity and reconfigure hospitals. The STP brand as a consequence was politicised.‘ Chris Ham said, “sadly STPs got off to a very bad start, a very difficult start because of that.“
An inquiry should surely legitimise those questions not seek to undermine them. It may disagree with them and may give good reason for disagreeing but for committee members to publicly cast doubt on the professionalism, expertise and authority of that legitimate challenge is unacceptable.
- It was highly selective in its evidence and timid in its conclusions
The call for written evidence was based on the committee’s previous inquiry which had been scheduled to take place before the General Election was called in 2017. The original inquiry asked whether Sustainability and Transformation Plans (STP) were working but by the time the committee heard the oral evidence the name of the inquiry had been changed and questions focused on the benefits of integrated care and the practical steps needed to implement it.
The Royal College of Emergency Medicine, representing one of the areas most significantly affected by the Five Year Forward View and all its subsequent manifestations, put in a written submission which not only challenged the evidence on which the assumptions for changed were based but also were highly critical of the language used in such consultation as had taken place.
Several submissions came from NW London, where the four local councils organised an independent review into the changes in their area in 2015. Their highest priority was where the cuts were falling and what impact it was having on communities with high levels of deprivation. The submission from Hammersmith and Fulham Council itself was particularly strongly worded, calling the consultation ‘stage-managed’, ‘tokenistic’ and ‘geared towards achieving a set outcome’. They go so far as to state that what has been done actually ‘flies in the face of evidence and feedback received from social care providers’.
With this background the Committee had little choice but to include some campaigners and challengers to the process to give oral evidence. Tony O’Sullivan from KONP gave examples from his own work of what integrating services really means and how they take a long time and dedicated work to achieve. It bears little resemblance to the top-down organisational and budget merging of ‘Integrated Care’. Allyson Pollock argued on the technical details of accountability and the legal framework.
Although the terms of reference nominally remained the same, the direction of questioning at the oral sessions was undoubtedly pointed more towards whether integration was a good thing and how it could be made to work rather than examining the problems of the STP process.
The inquiry sets out its stall as having the patient at its heart. Yet most of this evidence is absent from its report. The concerns arising from the written submissions was largely dealt with under conclusions such as this in section 64:
‘STPs got off to a poor start. The short timeframe to produce plans limited opportunities for meaningful public and staff engagement and the ability of local areas to collect robust evidence to support their proposals. Poor consultation, communication and financial constraints have fuelled concerns that STPs were secret plans and a vehicle for cuts. These negative perceptions tarnished the reputation of STPs and continue to impede progress on the ground. National bodies’ initial mismanagement of the process, including misguided instructions not to be sharing plans, made it very difficult for local areas to explain the case for change.‘
The oral evidence was dealt with in a more tortured and convoluted way. The report is a mass of contradictions. Far from presenting ‘compelling evidence’ it trips over itself trying to avoid the evidence staring it in the face:
- They agree with Allyson Pollock that ACOs need primary legislation. But they would like to trial a few first – how can a trial be run of accountable bodies which need primary legislation, without the legislation?
- They agree that the success of integration depends on the strength of local inter-disciplinary working, but accept that the 44 ‘footprints’ which are the boundaries of the Sustainability and Transformation Partnerships are not all well drawn and leave areas incoherent. They make no recommendation to address this.
- They accept the need to address the NHS’ financial constraints then admit there is no evidence integrated care does this. Indeed, far from being compelling, the evidence gives their claims the flimsiest of support.
As an extraordinary rider to the Inquiry’s title change the report effectively dismisses the STPs as no longer having any relevance, notwithstanding the amount of money that has been spent on them and that they were a critical step in the implementation of the 5 Year Forward View. Section 92 says that the Partnerships which have succeeded them are ‘fragile’ and must ‘not (be) overburden(ed) by increasingly making them the default footprint for the delivery of national policies’ despite that being precisely their purpose.
In short, these contradictions, inconsistencies and timidity means it ends up as a report of no consequence. It tries not to offend but to our mind it fails even that very limited objective. Indeed, there are times when it is hard to supress a laugh as the report says, time and time again, that there is no evidence in support of this plan – but they support it anyway.