NHS England pushes for “integration” … but not as we know it

John Lister (editor Health Campaigns Together, co-editor The Lowdown)

This is an opinion piece – it is not SHA policy

Despite all the other issues that might be expected to be priorities, it seems NHS England remains focused on driving through its plans for yet another reorganisation, to establish a network of 42 “Integrated Care Systems” (ICSs) to control services at local level – and possibly even fewer than that, with the possibility some smaller ICSs might also merge

A new 39-page NHSE consultation document “Integrating Care” at the end of November follows on from a volley of instructions to local health chiefs in a circular on July 31, which appeared to be about rebuilding services after the first peak of Covid infection, but took the opportunity to drive forward the process of merging Clinical Commissioning Groups (CCGs) and establishing ICSs in a final page of instructions.

The new document piles on pressure for prompt government action, setting an ambition of securing new legislation that would allow the whole of England’s NHS to be run through ICSs by 2022.

It makes the extraordinary claim that the establishment of ICSs – driven relentlessly from the top by NHS England, and resisted at local level by local government bodies, GPs and campaigners – is in fact “a bottom-up response.”

It rehearses the stock arguments for creating ICSs, with lofty, inflated and largely baseless claims that the handful of early ICSs “have improved health, developed better and more seamless services and ensured public resources are used where they can have the greatest impact.” In fact all the improvements that have been made along these lines have been made under existing legislation, with ICSs, lacking power or authority, having been able to do little or nothing.

There are also multiple references to “digital” and “data” as ways of driving system working and improving outcomes, despite the lack of evidence for these claims. New “digital” technology and number-crunching for “population health management” are among the more lucrative areas in which private companies from the US and elsewhere are seeking to gain a profitable foothold, not least through the Health Systems Support Framework established by NHS England.

Many campaigners remain justifiably suspicious of the extent to which ICSs, which have been set up and function largely in secret, would be in any way accountable to local communities if given statutory powers.

And while Integrating Care argues for the need to establish ICSs as “statutory bodies” with real powers, notably “the capacity to … direct resources to improve service provision,” there are real fears that NHS England, facing more years of tight and inadequate budgets, sees ICSs and system-wide policing of finances as a way of more ruthlessly enforcing cash-cutting reductions or restrictions on availability of services through “control totals” limiting spending across each ICS, and growing lists of excluded “procedures of limited clinical value”.

The HSJ, normally happy to go with the flow of NHS England, has pointed out how vague are the proposals in the new document, and raised questions over funding:

“While the paper makes it clear the current system doesn’t work, it gives little indication of what a better solution will look like and how that efficiency drive will be maintained.

“For example, it said ICSs will be given a ”single pot” of money from which to manage spending priorities. But there is no framework for how this will be spent that assures fairness, value for money and quality outcomes.”

Integrating Care suggests two alternative routes to establishing a legal status for ICSs; one by setting them up as new “joint committees” once the remaining unmerged CCGs had been merged to leave one per ICS, with the resulting loss of local accountability. The joint committees would enable NHS “commissioners, providers and local authorities” to take decisions collectively, although NHSE admits that this leaves “many questions” about accountability and clarity of leadership unresolved.

In the second option an ICS would effectively take the place of a CCG, replacing its governing body (along with its GP membership model) with a new board consisting of representatives from the “system partners” – including representatives of NHS providers, primary care and local government alongside a Chair, a Chief Executive and a Chief Financial Officer. In other words the CCGs, having been merged into bodies far larger in scope than the original 207 CCGs, would be abolished, with their commissioning role taken over by the ICSs.

This second model is the one favoured by NHS England. But it has raised concerns amongst GPs, some of whom fear that they and primary care as a whole would once more be marginalised by new structures that could be dominated by bigger providers, and especially by large-scale acute hospital trusts.

GP Online has highlighted “alarm” among GPs over the development of ICSs, and a recent motion adopted by Doctors in Unite which warns:

“ICSs 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.”

NHS Providers, representing trusts and foundation trusts, has also expressed some reservations, warning that:

“It makes sense to collaborate and deliver different services at different levels of scale, but all of these partnerships will need appropriate resourcing and cannot necessarily continue operating from within the existing staff base. …

“What we do know is that trust leaders – and partners from across the health and care system – are cautious about any top-down, inflexible reorganisation of the NHS, particularly in the middle of a pandemic.”


Will ministers back NHSE plan?

While NHS Providers expect an NHS Bill to be announced in the next Queen’s Speech and introduced in the late spring next year, this is up to ministers. In pushing hard and publicly now for legislation NHSE might be motivated by concern that the Johnson government (whose manifesto this time last year promised legislation to carry through NHS England’s Long Term Plan, which includes ICSs) may have since changed tack.

Last month the Department of Health published outline plans for “Busting bureaucracy” which appeared to back the NHSE approach, and committed to “bring forward legislative reform to reduce bureaucracy and promote collaboration across the health and care system,” building on “previous NHS recommendations to remove the two current procurement regimes which apply to clinical healthcare services and replace them with a new procurement regime.”

However revelations that Matt Hancock had been held back during the summer from plans to speed through the promised changes, and that  a secret Downing Street “task force” on health policy has been meeting over the summer and autumn – without inviting NHSE chief executive Sir Simon Stevens – suggest the PM may have been steered away by his advisors from what appeared to be a common agenda.

The only legislation on the NHS since last December’s election gave Johnson a Commons majority of 80 was to lock in the government’s inadequate promise of an extra £20 billion in real terms (£33.9bn in cash terms) by 2024 – effectively limiting government health spending.

And while the Covid pandemic has clearly preoccupied ministers and MPs since the early spring, the lack of any firm timetable or commitment for government action does raise the possibility that they have pulled back from the new legislation which NHSE argues is necessary to roll back key sections of the 2012 Health and Social Care Act – and pave the way for ICSs.

However we should not confuse NHSE’s moves to limit the requirement to put services out to tender with rolling back privatisation. As we have seen with so many Covid contracts, awarding contracts without competitive tender does not by any means end privatisation – or the “market” in health care, separating purchasers (commissioners) from providers.

The whole focus of NHS England’s proposals is on limiting contracting and competitive tendering …  to clear the way for even large-scale mergers of providers, which are free to involve the private sector as “partners” or as sub-contractors.

The Lansley Act’s version of tendering has already to a large extent been supplanted by the proliferation of “Framework contracts” in which NHS England or its privatisation sub-division NHS Shared Business Services sets up a list of pre-approved providers including private companies, non-profits and some NHS-led organisations, which can be allocated contracts WITHOUT formal tendering or competition, or from which a small group can be selected for a ‘mini-competition’.

Because no public process or advertisement is required, this type of contracting out/privatisation can take place with little or no public scrutiny.

So far, regardless of the government’s obvious hesitancy, it appears that the consensus assumption within the NHS is that NHSE will get legislation along the lines it has requested.

Even then there are many unknown factors. How far does Johnson’s clique of advisors really want to go with NHS reform? How fast?

How much priority can they and will they give it as Brexit chaos breaks out from January?

Do they really want now to marginalise Stevens and replace him with a more pliable Tory crony like Dido Harding – who would lack any credibility with NHS chiefs?

What we do know is that whatever the organisational changes, without additional revenue and capital funding and a properly resourced workforce plan the NHS is headed for constant crisis.

And for the Johnson government to assert greater central control over the NHS as it fails, or visibly attempt to privatise the most popular public service would be risking electoral disaster. We will have to wait to see which way they will go … and whether Johnson will – as rumoured – reshuffle his government, or even seek an early exit from Downing Street.

Problems for campaigners

There are also tough decisions for campaigners on how best to respond. The process of transition from CCGs towards ICSs is already well-advanced with the majority of CCGs already merged, and 29 of the target 42 ICSs now formally in place. This makes any nationally coordinated campaign extremely difficult.

However the mergers have also served highlight the fact that defending the status quo against NHS England’s plans is also a non-starter, since merged CCGs are already showing themselves more than capable of implementing policies as bad as many fear from ICSs.

In Nottingham, for example, the merged CCG covering the city and the whole county has embarked on a vicious combined attack on one of the best performing primary care practices in the area, putting the services up for tender while slashing the per capita funding by over 40% – with a subsidiary of the US-owned Centene corporation apparently lined up to snatch the contract.

With CCGs as bad as this, and with as little accountability to local communities, ICSs could prove to be little worse.

So while campaigners will continue to resist the forced mergers of more CCGs, the wider campaigning goal must not be limited to retention of the structures created by the 2012 Act.

NHS England want to repeal only selective parts of the Act. But to create any chance of genuine local accountability it’s necessary to scrap the remaining elements of the Act and the competitive market and purchaser/provider split it entrenched, to roll back tendering and privatisation, and create unified local health boards.

In other words the alternative would be genuine re-integration of health services split asunder since the days of Margaret Thatcher. However there’s no sign of any government appetite for such progressive reform, or of opposition pressure in this direction.

So with the Johnson government still bolstered by a huge Commons majority it appears that for the time being genuine integration is an ambition that is largely limited to propaganda, while campaigning focuses on exposing the flaws in the current system and fighting every move that advances privatisation.

(This article is adapted and updated  from an article in The Lowdown (December 6).