You’d be forgiven for not knowing that we are in the midst of even more reorganisation of the NHS. It is in part an attempt by the NHS leadership attempt to reverse the impact of the Health & Social Care Act via any means that does not require primary legislation. Everyone now seems to acknowledge that the top-down reorganisation has been as much of a disaster as Labour warned that it would be at the time.
In some ways, reversing the Lansley legislation and bringing health and social care services together in a fully public system is what Labour has been arguing for. But these aspirations are not going to be possible without far more investment, more rational funding, reversing privatisation and an end to the obsession with markets and competition.
The behind-the-scenes changes are like a parallel universe and none of this has been brought before parliament. No effort has been made to keep the public informed – the Health Secretary hasn’t even put out a press release.
One change being sought by the government is the creation of new bodies, known as Integrated Care Providers (ICPs). Although they could radically alter the entire health and social care landscape if widely adopted, this is all taking place without a vote or even a debate. ICPs will be responsible for running health and social care services in an area for up for up to ten years and, controversially, the contracts can be awarded to private companies.
When challenged on this, the government has tried to reassure people that the process won’t increase privatisation in the NHS. However, during a debate on the new proposals in parliament, health minister Stephen Barclay MP was asked four times by Conservative, SNP and Labour MPs to expressly rule out the new organisations being run by the private sector and he failed to do so on every occasion. The cross-party health select committee has called on the government to do the same, and they cannot offer a credible explanation for their refusal to do so.
The latest acronym for what you may have previously heard being called an STP or an ACO, ICPs are the latest manifestation of a process that has been going on behind the scenes for over two years. This new iteration adds even more confusion, as similar terminology around integration has been used to describe entirely different local models underway in other parts of the country.
Whatever the potential merits of the attempts to bring services together, the process has managed to alienate almost everyone as there was no proper consultation or engagement locally with public, patients or staff. Ambitious sounding STP “plans” fell apart under the mildest scrutiny as the money required for delivery was missing. Wildly optimistic assumptions about “savings” were literally incredible.
This approach was also characterised by the bewildering array of acronyms and complex terminology that has had the effect of shutting the public out of the debate around the future of the NHS. I don’t believe that this has been an accident.
The details setting out what an ICP will do were published during the summer recess, with no publicity – despite recent high-profile court cases that sought to prevent the process from continuing without new legislation being introduced. While very careful drafting means that these changes can technically be made without new legislation, it is clear that this process could mark a radical change to the way in which our health and social care services are organised.
Under the latest proposals, a contract will be awarded to a provider who will be given an annual payment to deliver a wide range of services. It will be compulsory to advertise the contracts to the market, and commissioners are forbidden from discriminating between NHS and non-NHS bidders. Bids can also be made by groups of organisations, so an NHS Trust or a group of GPs could partner with a private company. Previous high profile attempts to do this kind of thing in Staffordshire and in Cambridge collapsed spectacularly with millions of pounds wasted.
Worryingly, one of the criteria used to assess bids will be “whether they are able to deliver value for money”. This marks a significant change to the status quo. While there are clear issues with the current arrangement, it was introduced with the aim of ending competition based upon price and instead to focus on quality and choice. I do not believe that such a fundamental change should be made without the consent of parliament.
It is less than clear what will happen in the event that an ICP ends up in deficit, particularly where a private sector organisation or charity has won the contract. While the consultation documents set out that efforts that will be made to ensure that ICPs are financially viable, the same assurances have been offered about the existing configuration and almost half of all NHS providers were in deficit last year.
A new payment model proposed to fund ICPs where they are adopted will be known as a ‘whole population annual payment’, or WPAP. The ‘population’ to which it will be provided is not the actual population living in the area, but the number of people who have registered with their GP. This could lead to a significant under-representation in some areas and therefore under-funding.
If the WPAP is not sufficient to deliver the current levels of service, the ICP will be responsible for “managing changes in demand”. While there are merits in a system that incentivises keeping people well, there is a clear danger that “demand” will be managed by rationing access to some treatments. It is far from clear who ultimately would make these decisions on rationing nor how they would be accountable for such decisions. Transparency is a key concern. And all of this raises the spectre of a new postcode lottery, where patient experiences are uneven depending on whom is contracted by an unaccountable panel of commissioners.
The whole approach is simply a farce and part of a smokescreen to hide the huge damage done by years of austerity, made worse by the waste of market reforms and privatisation. Until a Labour government removes all the market architecture and restores a proper public care system, these messy, secretive and ill-conceived Tory reorganisations will continue in perpetuity.
Justin Madders is shadow health minister and MP for Ellesmere Port and Neston.