By Nick Davidson
On July 6th, the new Secretary of State for Health, Sajid Javid, unveiled the much heralded Health and Care Bill in Parliament, the second radical overhaul of the NHS in ten years.
The government says it will, “strip away unnecessary legislative bureaucracy, empower local leaders and services and tackle health inequalities.”
In fact the opposite is likely to be the case but the Bill has been snuck in just before the end of the Parliamentary Session and is therefore likely to receive minimal scrutiny. It raises a number of important issues.
The first and most obvious is that there is no mention anywhere in the Bill of two vital issues facing the health and social care services today: money and staffing. We spend less on health care and have fewer beds, doctors, and nurses per capita than any other comparable country. At the same time, cuts to local authority services are undermining social care and public health provision. Any government proposal that doesn’t address these two fundamental issues is deliberately ducking central concerns.
The Bill is jargon-riddled – much of it drawn from the US health insurance industry – and appears complicated. But at heart it’s pretty simple.
- It takes back control of the NHS from the unaccountable, undemocratic, quasi-governmental body, NHS England, and brings it back under the direct control of the Dept of Health and Social Care. That’s a plus – but see below.
- It abolishes the current NHS structure and reorganises it into 42 so-called regional Integrated Care System (ICS) boards which cover the whole of England, a recognition that the current fragmentation of the service isn’t working. Another plus – but again see below.
It’s said the ICS boards will operate as a partnership between the NHS, local authorities and an approved list of private providers. That would be an improvement if it were as simple as that. In fact the evidence suggests the new ICS boards will only be accountable upwards and there will be an almost total absence of local accountability.
Local CCGs (Clinical Commissioning Groups), which currently run local health care, will lose any independent decision-making power and the only avenue of local accountability will be through one or two, possibly non-voting (it’s not clear yet) local authority reps who will sit on each ICS board.
There’s no mention of representation for patients and public, no requirement on the ICS boards to meet in public or to publish board papers and minutes. They may even be immune to Freedom of Information requests.
Some of this secrecy is being driven by the increased role of the private sector.
The private sector
Much has been made of the fact that the White Paper removes the obligation on the NHS to put contracts out to competitive tender. Another giant improvement but it comes with a sting.
It will be replaced by a system under which some 200 private companies will be accredited, through a body known as the Health Systems Support Framework, to provide services to the NHS. These companies will be given direct access to the health service. Forget competitive tendering: indeed, they will be given seats and voting rights on ICS boards. In other words, they’ll become part of the NHS decision-making process.
Who are they? At least 22 of them have their headquarters in the US. They include management consultants like McKinsey, Deloitte and Ernst and Young, multi-billion global insurance and data companies like Optum, Centene and Cerner, and private health providers such as Virgin.
The presence of these companies is already leading to reduced public accountability. For example, the Virgin Care director on the board of the ‘shadow’ Bath, North East Somerset, Swindon and Wiltshire ICS, has made it clear he’s not prepared to share company information with the wider public. As a result the board has agreed not to make public much of its activity in order to protect corporate and commercial interests.
The BMA, in its comments on the White Paper, has written: “The White Paper takes the first step to abolishing (competitive tendering) rules, but unless it goes further – making the NHS the default option for delivering NHS services – there is a risk that contracts will be awarded without scrutiny to private providers at huge expense to the taxpayer, as was seen with the procurement of PPE and Test & Trace during the pandemic.”
The Bill, in short, bakes in a public/private partnership that will encourage a less open and democratic NHS.
The concept of an Integrated Care System carries with it the idea of a welcome increase in the integration of health and social care and better social care provision. Excellent.
But sadly the Bill defers any significant reform of the social care system and leaves us with a peculiarly ad hoc form of integration between the two services.
Under the Care Act Easements of 2020, part of the Coronavirus Act of 2020, health authorities have been encouraged to ‘streamline’ the assessment of needs of patients before leaving hospital, prioritising the most urgent and leaving the rest to take care of themselves. As a result over the last 12 months some 80 percent of people discharged from hospital have never received an assessment at all. This is not integration but expediency.
Meanwhile, plans for improved Public Health generally are largely restricted to calling for tighter regulation of food advertising and labelling in the name of tackling obesity.
With local authority resources stretched to breaking point, token local authority representation on ICS boards and an increased role for the private sector, there’s a real fear Integration will be in name only and social care will continue to be a Cinderella service.
The Bill makes much of the benefits of greater digitalisation, particularly in primary care. This may be true – up to a point. But part of this digitised improvement involves replacing face to face doctor/patient consultations with digitised meetings.
Centene, the US insurance giant which recently acquired 58 GP practices across England, has for example, emphasised the benefits of a greater use of digital consultations. But the evidence suggests these are, in fact, much less beneficial for all but the most straightforward and simple health issues.
Furthermore greater digitisation raises all the issues currently associated with the Government’s controversial plans to set up a central, digitised, patient records system.
Finally, there’s the issue of funding arrangements. Each ICS will be allocated an annual capped pot of money, based on a set of centrally determined targets. The question is who determines the targets and how realistic is the capping.
In the past, health authorities have been able to roll over deficits and seek bailouts. Capped budgets will remove this flexibility and inevitably lead to further rationing.
Targets may also lead to unexpected difficulties. For instance, the Dept of Health may decide every ICS must increase treatment at home by 2% per year and to achieve this it will limit funding for GPs referrals and reduce funding to hospitals.
Such an arrangement not only interferes with the clinical judgement of GPs but takes no account of the circumstances of the local population. In wealthy, well-housed areas it may make sense: in impoverished areas with poor, overcrowded housing and high unemployment, it may not.
In short, it shifts the focus from universal comprehensive health care based on individual need to a centrally targeted system based on generalised data and political imperatives.
In summary, the Health and Care bill is a missed opportunity to fundamentally improve – let alone integrate – the health and social care services. It ducks the big issues of funding and staffing, reduces local accountability and bakes in a greater role for the private sector.
Nick Davidson is a proud member of Haringey Keep Our NHS Public and Islington North Labour Party.
Image: anti-Centene demonstration outside the Dept of Health and Social Care on July 5th, taken by the author.
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