Nobody believes these intentionally complex, indecipherable, snake-oil legislations are designed to improve the NHS & Social Care...
Rather, they make provision for US style "health care"-where fraud, mega-profits, exclusion of expensive patients, basic care, with private health insurance to top up-if you can afford it...
US style UnAccountable Care Organisations, DisIntegrated Care Boards-all designed to move to a profiteer health scheme, for the benefit of investors , Milburn, Lansley, Hunt etc in healthcare (MPs, Lords, hedge funds etc)
The end of the free, equitable, great value, good outcomes NHS-when the government does not actively and intentionally dismantle it!
Camden Council meeting, Monday 24 January 2022 at 7pm
Request to make a deputation on the Health and Care Bill By Peter Roderick (Camden resident, in person) and Professor Allyson Pollock (remotely)
The Health and Care Bill is currently at its Committee stage in the House of Lords, having already passed through the House of Commons.
We request to make a deputation to the Council to provide a brief outline of the implications of the Bill’s structural changes for the Council and for people living in Camden.
We previously made a deputation on the Bill to the Council’s Health and Adult Social Care Scrutiny Committee meeting on 13 December 2021.
We set out in section A below the key points we wish to present to the Council. In section B we provide some more background detail on the structural changes, along with a summary of structures which are omitted from the Bill but which are necessary to understand its implications. We set out what we are asking the Council to do in section C. A.
1. The Bill moves health services in England closer to the US model of mixed public and private funding, and mainly private provision, with several of the same features and risks of increasing costs and widening inequalities in access to and outcomes of health care.
2. It does this by completing the detachment of funding, planning and provision of health services from local people living in local areas, replacing it with a system based on membership or enrolment of the population into 42 Integrated Care Boards (ICBs).
The shift to membership mimics the US system where private insurance companies receive public funding to cover eligible individuals, not to cover the local population.
3. Each ICB will be given a single budget pot to commission most health services but will only have “core responsibility” for a “group of people” drawn from anywhere in England and allocated to it under rules prepared (not yet published) by NHS England, without parliamentary process.
4. “Core responsibility” is a new concept which evokes the US definition of a health maintenance organisation, which arranges ‘basic’ and ‘supplemental’ services for its members. Supplemental services generally have to be paid for by further insurance or user charges.
5. Private companies will be entitled to be appointed members of ICBs and their committees which will decide how the budget pot should be spent – a government amendment in the Commons may limit but will not prevent this.
6. The Bill also establishes Integrated Care Partnerships as joint committees of ICBs and local authorities to draw up an integrated care strategy. They will have little power, and should not be confused with ‘place-based partnerships’ which are non-statutory and have no required governance or procedures.
7. ICBs are a veneer. Real power, decision-making and influence will lie with 4 public and private groups that are not mentioned in the Bill and whose membership, governance and procedures as 2 groups are not regulated. These are ‘provider collaboratives’, ‘place-based partnerships’, ‘primary care networks’, and companies accredited to the Health System Support Framework. These groups are already in place and working outside the statutory radar.
8. The ICBs can delegate functions and pass budgets through contracts to provider collaboratives who NHSE says will design services.
9. Commissioning contracts can include ‘discretions’ in relation to anything to be provided under the contracts – i.e., providers can decide what, where, and how services are to be provided. These ‘discretions’, and the introduction of ‘core responsibility’, signal that the levels and kinds of NHS services available will be reduced, and supplemental services will be provided to those who can afford to pay.
10. Provider collaboratives are another US feature, echoing the ‘provider networks’ of the private insurance companies. In the US government money can pass to insurers which make contracts with a limited number of providers to buy services for their plan members, known as ‘provider networks’. Out-of-network providers can require extra payment or deny services.
11. The blurring of the boundary between funding and provision marks a further shift to a two-tier system. Providers of NHS services can advertise private services, or requiring patients to top up basic services by paying for supplementary services. This is happening now, as NHS foundation trusts can receive 49% of their income from private patients and other non-NHS sources.
Below are screenshots of the websites for UCLH’s private services and for its joint venture partner, HCA Healthcare UK (Hospital Corporation of America) which describes itself as ”the largest private healthcare provider in the world, and the largest provider of privately funded healthcare in the UK”.
12. An ICB will not be required to arrange provision of emergency services for everybody present in its area – unlike a CCG.
13. The national tariff will be abolished, as will procurement rules for competition and commercial contracting. Market deregulation means that providers through their networks will be free to set staff pay and prices. This is currently the situation for long term care. Networks of providers are 3 likely to operate as cartels and use their monopoly power over prices. This will result in a major increase in health expenditure.
14. Money will increasingly leak out to shareholders and equity investors. Virgin Care has recently been taken over take over (£) by a private equity firm; The Priory Group for mental health services was sold in December 2020 to a Dutch equity group for £1.08 billion. HC-One, the UK’s largest care home operator, was reported on 6 December 2021 to have moved profits offshore to private investors.
15. The Bill will require service reconfigurations to be referred to the Secretary of State instead of being dealt with locally, and a local authority’s referral power will be “amended” (in ways which have not been set out).
16. Local authorities will have little influence over decisions, as ICBs will not be responsible for local populations, and include several local authorities.
B. Background detail The NHS in England is moving to 42 Integrated Care Systems (ICSs). These are not defined in the Bill, and are only mentioned in headings or in passing. This is because they are only partly and minimally statutory. They are mainly non-statutory, with real power, decision-making and influence lying with non-statutory groups whose membership, governance and procedures as groups are not regulated. The statutory parts are Integrated Care Boards and Integrated Care Partnerships. The non-statutory parts are provider collaboratives, place-based partnerships, primary care networks, and companies accredited to the Health System Support Framework. 1. Allocations to ICBs and “core responsibility”
The Bill abolishes clinical commissioning groups (CCGs) and replaces them with Integrated Care Boards (ICBs). An ICB will be responsible for commissioning most health services, but not for everybody living in its area. Everybody receiving primary care services or who is usually resident in England must be allocated to at least one ICB under rules to be made by NHS England (NHSE) without parliamentary process.
This is the first time since 1948 that Parliament does not determine to whom NHS services must be provided. Allocation to an ICB (North Central London in Camden’s case) does not require a person to live in Camden, or in NCL. It is currently unclear to what extent people will be able to choose ICBs and to take the budget with them (as in the Babylon case); and to what extent ICBs will be able to challenge allocations and thereby in effect to select patients. The Explanatory Notes to the Bill state: “It is expected that the basis of NHS England’s general rule for ICB responsibility will continue to be in relation to GP registration to ensure operational continuity”. The people allocated to the ICB will be the “group of people” for whom the ICH has “core responsibility”.
This new concept closely resembles the US definition of a health maintenance organisation (HMO).
In the US, contrary to popular perception, the government funds most healthcare, much of it through private health companies such as HMOs and other “managed care organisations”. These are responsible only for providing limited free services to a group of people who enrol as their “members”, not a local population. They provide a core or basic package of care paid for under a health plan. Additional services are paid for through more insurance or user charges. The Committee is already aware that US private health companies already operate in Camden, such as Centene (Operose).
2. ICB membership ICB members will consist of: ? A chair, appointed by NHSE with the approval of the Secretary of State, ? A chief executive, appointed by the chair with NHSE’s approval, ? At least one1 member nominated jointly by the NHS trusts and NHS foundation trusts that provide services in the ICB’s area, approved by the chair, ? At least1 one member nominated jointly by those providing primary medical services in the area, approved by the chair, ? At least1 one member nominated jointly by the local authorities in the area, approved by the chair, and ? Anybody else approved by the chair. In response to criticism that private companies could be members of ICBs, the government has introduced an amendment requiring ICB constitutions to prohibit a person becoming a member if “the appointment could reasonably be regarded as undermining the independence of the health service because of the candidate’s involvement with the private healthcare sector or otherwise”. This will not rule out private companies sitting on the ICBs or their committees. Unlike CCGs, ICBs will not be required to have the letters “NHS” in their name.
3. Integrated care partnerships 1 The words “at least” were inserted by the government during the third reading in the Commons, after a similar Labour amendment (which extended to representatives of trade union and patients) had been defeated.
5 Each ICB and the local authorities must establish a joint committee termed an Integrated Care Partnership (ICP) with no additional minimum membership requirements or constitution. Each ICP must prepare an integrated care strategy setting out how needs identified in the joint strategic needs assessment will be met. Four points to note. First there is a mismatch between a local authority’s responsibilities for residents in its area, and ICBs (currently, CCGs), which are responsible for groups of people who may be drawn from throughout England (currently, from GP lists). Second, public health was carved out of the NHS in 2012. Many public health functions including intelligence, data analysis, needs assessment, health service planning, and commissioning are now undertaken by commissioning support units, some of which are privatised, or outsourced to companies accredited to the Health System Support Framework, such as PWC and Optum (UnitedHealth), which in future will be operating on behalf of ICBs or provider collaboratives. Third, the current JSNAs and health and well-being strategies for both Camden and Islington appear to be broad in their scope and largely descriptive, drawing on secondary data from Public Health England, ONS and other sources and setting high level targets. A detailed needs assessment to inform local health service planning would require surveys of local people’s needs, identification of unmet need, detailed analysis of what services are provided and where locally, staffing levels, service access utilisation and gaps in service provision to meet that need. For example, mental health services have been identified as a need in the JSNAs for both boroughs. While Camden has local providers, many acute mental health services are increasingly contracted out to large FTs and private providers remote from local people, e.g., The Priory Group and Cygnet. Local residents and children and their families may have to travel hundreds of miles to access care. It is hard to see how these major gaps in local provision would be remedied through the JSNA. Fourth even if a needs assessment for services were to be undertaken, each ICB must only have regard to the integrated care strategy, but ICPs cannot require its adoption. ICPs are unlikely to have much sway. According to the NCL CCG website: “Integrated Care Partnerships will commission some local services while there will be a number of services that are commissioned at North Central London level, through the NCL Integrated Care System.” But commissioning services will not be a statutory function of an ICP. We wonder whether the website is confusing ICPs with place-based partnerships (see section 4 below). An ICP only has one central statutory function – to prepare the integrated care strategy. 4. The groups not mentioned in the Bill ICBs are the veneer; ICPs are weak and limited. The real power, decision-making and influence will lie with four groups that already exist but are not mentioned in the bill: provider collaboratives, place-based partnerships, primary care networks, and companies accredited to the Health System Support Framework. Provider collaboratives Provider collaboratives are groups of public and private providers that NHS England has said will be responsible for designing services. ICBs will be able to delegate their functions to them, and devolve 6 the budgets to them. Their membership, legal form and governance is unregulated. Yet NHSE describes them as being “a principal engine of transformation”.
As Andrew (now Lord) Lansley said in the second reading debate: “we have new provider collaboratives which, in fairness, is where the power in the NHS will lie. The Bill makes no provision for them in terms of transparency, openness or accountability.” This was also confirmed on 2 December by the Health Service Journal: “In the minds of most acute trust chiefs, it is provider collaboratives and groups, and not integrated care boards that will wield the greatest influence (although the former may act through their representation on the latter). Many believe ICSs will become tiny organisations effectively operating as a population data provider for collaboratives and “place-based partnerships”, or disappear altogether.” The bill also proposes that commissioning contracts can include “discretions … in relation to anything to be provided under” the contracts. In practice this will allow providers to decide what, where and how services will be provided. So much for our so-called rights under the NHS constitution. More than 40 collaboratives are listed on the NHS England website, including several private companies such as Cygnet, Priory and Elysium. There are echoes here again of the US. In the byzantine US healthcare system, private insurance companies sell health plans to individuals, some of whom may be eligible for public funding. The private insurance companies enter contracts with a limited number of providers to buy services for their plan members, known as “provider networks”. An ICB will be able to operate similarly, with similar effects, for its group of people. The Northern Care Alliance is already reported to be doing this. In effect, this leaves the principle of a universal and comprehensive NHS in tatters. Place-based partnerships Place-based partnerships will also be unregulated and have no statutory functions, even though NHSE and the LGA describe them as “the foundations of integrated care systems”. They should not be confused with ICPs. We assume some Councillors will know how these are developing in Camden/NCL. Decisions of whatever place-based partnership(s) Camden Council is a part of will legally be decisions of the NCL ICB. Primary care networks Following NHSE and BMA negotiations, 1,250 primary care networks are now in place, operating under network agreements, the contents of which are ‘not within the remit of the CCG to challenge’ (BMA). These are described by NHSE as “crucial to the development” of ICSs. The website of North London Partners indicates (in a news item) that there are 30 PCNs in NCL, and 7 in Camden, but the links were not working on 8 December 2021. Health System Support Framework NHSE states that this framework is “a quick and easy route to access support services from innovative third party suppliers at the leading edge of health and care system reform, including advanced analytics, population health management, digital and service transformation”. Over 200+ 7 companies have been accredited to this framework, including Atos, Capita, Centene, Deloitte, Ernst & Young, McKinsey, PWC, Serco and UnitedHealth. C. What we are asking the Council to do We ask the Council to consider voting on a resolution to oppose the Bill. If the Council decides not to do so, or if that resolution is not passed, we ask the Council to consider voting on a resolution to support substantial amendments to the Bill, including: (a) those tabled in the House of Lords- (i) to restore the Secretary of State’s duty to provide and secure NHS services nationally (Amendments 46, 168 and 1692 ), (ii) to require an ICB to arrange emergency services for everybody present in its area (Amendment 51A), (iii) to put place-based entities and provider networks on a statutory basis (Amendments 165 and 166), (iv) to limit integrated provider contracts to NHS bodies (Amendment 21), (v) to prevent private companies being members of ICBs and ICPs (Amendments 30 and 150), (vi) to prevent APMS contract holders from being ICB members and to remove future use of APMS contracts (Amendments 28, 55 and 56), (vii) to prevent fragmentation (Amendment 45), and (b) further amendments3 (i) to require the basis for allocation to appear on the face of the Bill, based on local residence, and to remove the concept of ‘core’ responsibility, (ii) to ensure that an ICB has the same public involvement obligations as a CCG, namely that the arrangements which the ICB must make for involving the public in the planning of commissioning, in developing proposals and in decisions on impactful changes are described in its constitution along with a statement of the principles which it will follow in implementing those arrangements, (iii) to ensure that an ICB’s constitution must, as a CCG’s constitution must, specify the members of the ICB and require its name to comply with any prescribed requirements, such as its name beginning with “NHS” in capital letters, and (iv) to retain NHS England’s duty to consult with Healthwatch England on commissioning guidance. PR & AP, 15/1/22 2 Amendment numbers are as per the Third Marshalled List of Amendments of 14 January 2022, available here: https://bills.parliament.uk/publications/44689/documents/1250. 3 Details of these further amendments can be read here.
Tentacles wrapped around the NHS
The Government agenda in the Health and Care Bill is not hard to decipher, despite repeated denials that the Bill has anything to do with privatisation, would fragment the NHS, or make it harder for patients to obtain the care they need. With an 80-strong Tory majority in the Commons, it is natural to hope that Labour Lords will ride to the rescue and neuter their plans. But so far, there few signs that Labour has grasped the overall purpose of the Bill, and there is at least one influential Lord whose amendments and extra-parliamentary interests tell a different story.
But first, recall some of the real issues.
• When it was first published in July, Allyson Pollock and Peter Roderick pointed out that the Bill did not define the group of people for whom an Integrated Care Board (ICB) will be responsible, and there is no requirement for an ICB to ensure that emergency care is provided for every person present in its area, a requirement for Clinical Commissioning Groups under current law. This will inevitably mean more bureaucracy and potential arguments as ICBs bill each other for people needing A&E while visiting their patch. People outside their normal area may also be denied emergency care, as has already happened in Greater Manchester, and this may affect undocumented migrants or anyone unable to prove they are “ordinarily resident” in the UK. Restricting access to emergency care is a body blow to the NHS Constitution and to medical and nursing ethics.
• Clause 68 and Schedule 10 introduce a new Payment Scheme to replace the national tariff. The Scheme will vary by area, patient and provider characteristics so that different organisations may be paid different rates for providing the same treatment, and treating “persons of different descriptions” may be assigned different prices. This highly variable Scheme will determine the ICB budgets, enforced by NHS England and controlling the overall spending by NHS providers in the area. That is why treatment will be rationed, differently in each area. This could mean treatments which are needed and available on the NHS in Chelsea are needed but not available in Birmingham to persons “of different descriptions”. Who knows how this will sit with the Equality Act?
Breaking the finances with different prices and budgets around the country is also an incentive to introduce local pay. Unite’s latest briefing seeks amendments to ensure that “the pay rates of Agenda for Change, pensions, and other terms and conditions of all eligible NHS staff are not undermined as a result of any NHS payment scheme”.
To top it off, the Bill requires NHS England to consult on the Scheme with “any relevant provider”, which explicitly includes private providers. So for example, NHSE must consult with G4S on the prices they will be paid for running Sexual Assault Referral Centres, a public health function. In the Commons, Margaret Greenwood’s amendments on the Scheme were never called and no-one else mentioned it.
• The Health Systems Support Framework (HSSF) was highlighted in KONP briefings and leaflets over the last year and a Guardian article by Pollock and Roderick on 7 December. NHS England has now accredited around 200 companies to support the development of Integrated Care Systems under dozens of topic headings, many of which concern data and digital transformation. At least 30 of the firms are US-owned and include transnationals servicing the health insurance market.
For example Operose, now facing Judicial Review after its takeover of London GP surgeries, is wholly owned by US transnational Centene, a $100bn enterprise whose Texas subsidiary Superior Health Plan denied care to disabled children and a quadraplegic adult. Under the HSSF, Operose is accredited for 22 topics, including population health management, business intelligence, personal health budgets and payment reform. As NHS England explain “the 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, including advanced analytics, population health management, digital and service transformation”. In other words, a Centene subsidiary whose former CEO advises Prime Minister Johnson may support ICBs in planning health care.
So far, the Lords have resolved none of these real issues. An amendment on emergency care was tabled by cross-bench peer Baroness Finlay but not voted on. An amendment from Labour Front Bench peer Baroness Thornton simply requires the Secretary of State to set out the rules for the payment scheme, and for NHS England to obtain their approval before publishing it. Ironically, the only Peer currently challenging the Payment Scheme is Lord Lansley, architect of the Health and Social Care Act 2012, who has declared his intention to oppose Clause 68! Nor is Labour committed to public provision of healthcare. An amendment from Lord Hunt, Baroness Walmsley and Baroness Thornton mandates each ICB to ensure diversity of provision within local areas including social enterprises and “independent providers” (the official NHS term for private sector).
Lord Hunt of Kings Heath has tabled some 60 amendments. He has a long and influential Labour career with a background in NHS management. Appointed as a life peer in 1997, Hunt served as Deputy Leader in the Lords and as Minister for Health (NHS Reform). In opposition after 2010, he was Shadow Deputy Leader, spokesperson on Health from 2012 to 2017, and then on Health and Social Care until May 2018. Previously, he was Chief Executive of the NHS Confederation 1996-97, and a Director of the National Association of Health Authorities 1984-96.
Hunt’s amendments include proposals that each ICB Constitution requires a Director of Digital Transformation, that the ICB produce a 5 year plan for digital transformation, to be included in their Annual Report, and that NHS England assess their performance under this heading. A key amendment requires that at least 5% of the capital budget for NHS England, each ICB, each NHS Trust, and each Foundation Trust must be ring-fenced for digital transformation.
NHS England guidance states that IT investment is included in capital spending envelopes, though national programmes funded through NHSX are excluded.
Lord Hunt is an officer of the All-Party Parliamentary Group on Digital Health, which connects Parliament with the health system, industry, academia, third sector organisations and civil society to develop the use of data and digital technologies in delivering health services. The Association of British HealthTech Industries, with 320 members, acts as the group’s secretariat and has given financial support to the APPG.
Meanwhile, Lord Hunt’s Parliamentary Register of Interests shows him as the paid Chair of the Advisory Board, Octopus TenX Health, a health technology investment company. The Advisory Board is not shown on the Octopus Group or Octopus Ventures site, but on 19 January 2021, just before Octopus took over, the TenX Health website with a page on the Health Advisory Board was captured by the Internet Archive. It explains:
We have established a world-beating extended advisory board to ensure every member of our investment portfolio has immediate access to the depth and breadth of skills and experience they need to scale rapidly into the UK, Indian and Chinese healthcare markets. Chaired by former UK Health Minister Lord Philip Hunt, the board consists of some of the most experienced founders and practitioners at the coalface of healthtech development in the UK and internationally, a leading academic in growth equity, clinicians leading the development of innovative models of care and the CEO of one of the most active care providers in driving technology adoption.
The Board included Joe Harrison, CEO at Milton Keynes University Hospital and married to Samantha Jones, former CEO of Operose Health (see above), now Prime Minister Johnson’s Expert Advisor for NHS Transformation and Social Care.
The Board also included Dr Umang Patel, Clinical Director at Babylon Health, Kate Robinson, Digital Ecosystem Leader at IBM UK, accredited for 22 topics on the HSSF, and Melissa Morris, CEO of Lantum, “a platform that uses Artificial Intelligence and Machine Learning to automate the manual processes involved in organising staff to fill clinical rotas”. The company is “on a mission to help save the NHS £1 billion in staffing costs” and accredited on the HSSF for Workforce Development, a topic which includes “the use of location tracking to enable worklist management, journey management and digital assignment, notification and monitoring of actions to care professionals, taking into account case load and case mix”.
Melissa Morris previously worked for the Strategy Directorate at NHS England and at McKinsey & Company as a Business Analyst Sep 2008 - Aug 2010, the period during which McKinsey advised the Brown government on measures to cut NHS spending after the financial crisis. Another Board member, Dr Nav Chana, is Chair of the National Association of Primary Care. An NAPC document written by Dr Pooja Sikka, GP and Partner, TenXHealth is entitled “How digital is changing the NHS landscape – take the leap or be left behind?” It has this gem:
Employer-led healthcare: Corporate and other employers provide access to clinical services, delivered by novel health technologies and integrated with private health services, rather than just health insurance for their employees. Employers have great buying power, and countless studies show the economic cost of ill health for the working age population both for the employer and the economy. Access to employer health programmes integrated with innovative health technologies is a likely future trend.
Black Swan moment
At the start of the first lockdown, Joe Stringer, health tech consultant and investor at TenX Health, declared that coronavirus could be the “catalyst” for the mass adoption of tech across the health system. He told the Health Service Journal (28 March 2020) “This could be the black swan moment for health tech... Some of the really big venture capital funds and family offices are now moving in this direction, because health is traditionally one of the safe havens for investors during a global recession, along with government bonds and gold.”
On 25 January 2021, Octopus Ventures, part of Octopus Group, incorporated a new team from TenX Health – including Joe Stringer and Dr Sikka - to launch a new “£100 million institutional global fund to take advantage of the health tech market opportunity”. In their words:
The opportunity to transform public healthcare systems across Europe and emerging markets is growing exponentially. Even before Covid, health technology was one of the fastest growing investment sectors but this pace has more than doubled as a result of the pandemic. As the rollout of the Covid vaccine commences, governments, healthcare providers and insurers around the world have recognised the vital role that technology and remote working can play in diagnosing and delivering safe and high quality care, regardless of how it is funded.
Indeed, that is the Government’s agenda, and Covid has opened the floodgates. Lord Hunt’s amendment requiring minimum 5% ringfenced budgets for digital transformation at all levels of the NHS is also signed by Liberal Democrat Lord Clement-Jones and Conservative Baroness Cumberlege, and is likely to attract wide support. It seems perfectly designed to guarantee a funding stream for the companies promoting these technologies, including those accredited by the NHS England Health System Support Framework, and perhaps even those with members on the TenX Advisory Board.
Many other peers, including 57 Conservative and 31 Labour, have corporate interests including healthcare, and Lord Hunt is no longer a Labour Front Bench peer. But he is still a commanding figure, already tabling 60 amendments for the Lords debate which started on 11 January.
When did the public, patients and NHS staff, give a mandate for the digital transformation of healthcare, as promoted by Lord Hunt?