Current proposals for integrated care, through new care models such as Integrated Care Systems and Integrated Care Organisations (ICOs) (previously called Accountable Care Organisations) raise a number of concerns.
Human Rights issues
NHS England’s proposals for integrating care are based on capitation-based payment systems, including ‘integrated’ or whole population budgets (WPBs) These fund services for a specific population over a specified period for fixed sum. Populations are defined according to registered patients lists, rather than by geographical area (the way in which universal care has been ensured up until now).
In addition, despite the minimum delivery standards set out in contracts, WPBs provide an inducement to raise treatment thresholds or ration some services in order to minimise costs, irrespective of the care that is actually needed. Capitation funding has been a feature of NHS local allocations since the 1970s and today is the basis for funding of CCGs. But the WPB approach to capitation funding – especially in the absence of adequate levels of funding – flouts the duty of government to care for all in society.
In these ways, introducing WPBs as the payment system to underpin integrated care potentially contravenes the NHS Constitution and is fundamentally at odds with an NHS based on the principle of social solidarity and the values of equity and universalism.
Governance, accountability and legal issues
ST Partnerships are introducing radically new ways of delivering care with scant public involvement or any meaningful consultation. This is despite the inevitable changes these new care systems will involve, and despite current law (HSC Act 2012) and statutory guidance.
Simon Stevens, CEO of NHSE, has said that he will give ST Partnerships governance rights over organisations within their local health system, including bodies such as CCGs or local authorities with statutory responsibilities. Currently, ST Partnerships (and the integrated care systems they may evolve into) are, by NHSE’s own admission, not statutory bodies: they have no legal power to make decisions without referring these back to partner organisations. The Conservative Party Manifesto of 2017 proposed changes by secondary legislation – without public consultation or Parliamentary scrutiny – to allow ICOs to operate.
ST Partnerships are introducing radically new ways of delivering care with scant public involvement or any meaningful consultation. This is despite the inevitable changes these new care systems will involve, and despite current law (HSC Act 2012) and statutory guidance requiring commissioners to directly involve the public in commissioning arrangements (such as plans to transform services and proposals to change procurement and contracts). ACOs and ICSs are presented as local bodies working in partnership with local communities but, in reality, they will be run as businesses with little accountability to local people. This is in breach of the NHS Constitution, which commissioners have a duty to promote. According to the Constitution, the NHS is accountable to the public, to communities and to the patients that it serves.
The HSC Act 2012 gave clinical commissioning groups (CCGs) control of most funding for healthcare services at the local level. Even though there has been no amendment of legislation so far, ICOs will transfer many of CCG responsibilities, including some commissioning of services, to potentially new organisations and these may not be NHS or local authority bodies. In addition, NHSE’s draft contract for organisations (Integrated Care Providers) commissioning and delivering the services on behalf of an ICOs shows that the contract holder could be a consortium of companies or even a Special Purpose Vehicle. This could give the private sector (including multinational companies) a significant role in the planning and commissioning of services, as well in as their delivery. There are some indications that ICOs will issue a ‘prospectus’, suggesting they intend to attract private sector funding.
Funding to run NHS and social care services is being significantly cut. Yet the Naylor Review, to which the government appears to be committed, estimates that the infrastructure necessary for new models of care will require around £10 billion of capital investment in the medium term. The review suggests that about £2 billion of this can be raised by the sale of NHS assets, notably land and buildings owned by NHS providers in the acute sector, while facilitating the building of 26,000 new homes. Naylor observes that, currently, even though their assets might be “of greater benefit in another part of the healthcare economy”, providers such as NHS Foundation Trusts tend to keep assets to fund their own interests and are unlikely to sell what they own to support others with different statutory responsibilities. However, Naylor sees that the introduction of ICOs will overcome this conflict of interest, persuading acute providers to invest their property assets in primary, community and mental health services as part of a collective responsibility within an ICO. According to the British Medical Association, land or building sales will be conducted through public/private partnerships (Project Phoenix), effectively undermining the social ownership of NHS assets while allowing private companies to profiteer from these.
Many ST Partnerships have used private consultants (e.g. McKinsey, Deloitte and PwC) to develop plans in order to meet the requirements of NHSE’s Five Year Forward View, including plans for new care delivery systems. It has been estimated that by February 2017, at least £17.6 million of NHS money had been spent on consultancy fees.
Some analysts fear that new ways of delivering care, especially ICOs, will provide a structure that, in future, could help facilitate the replacement of the NHS by private health insurance. Whilst the NHS as a whole is far too big to sell in a single transaction, ICOs will offer discrete local systems with budgets big enough to attract investors and potential takeovers, or – if the political circumstances allowed this to be considered – with organisational forms compatible with the US health insurance market.
There is little robust evidence from pioneer programmes in the UK to support the introduction of ACOs or ICSs to the NHS: by NHSE’s own admission, these programmes have been of short duration and provided only small sample sizes.
Ribera Salud hospitals that set up ICOs (or ACOs) in Valencia, Spain claim to have higher patient satisfaction rates, lower staff absenteeism, shorter average lengths of patient stay, lower waiting times and lower capitation costs than competitors. However, clear evidence is hard to find: reliable financial and contract information is limited, and there are serious concerns about the objectivity of data from the Ribera Salud company.
ACOs are usually associated with the US healthcare system, and may have influenced the drive towards ICOs in the UK. However, there is mixed evidence about the performance of US ACOs (still in their early days). In addition, the very different contexts in which the NHS and US health care system operate (not least the different levels of funding), and the lack of a standard model of care makes it difficult to extrapolate from the US experience or learn from cross-national experience more generally. As researchers from Manchester Business School put it, “Care is needed to avoid unwarranted inferences that this [ICO] policy will deliver the claimed benefits of lower costs whilst maintaining sustainable quality.”
ST Partnerships (and their successors, ICSs and ICOs) are expected to rely heavily on the co-operation of all their member organisations. Yet in September 2017, a survey showed that only one of 56 organisations involved in ST Partnerships believed that full joint working would be achieved in the next five years.
ICSs and ICOs will also have to accept a new form of financial control (a ‘system control total’) in which financial risk is shared across the whole local health system: individual providers within the system must set aside their own interests and allow any surpluses they make to be used to offset losses that have been run up elsewhere within the system. Failure to keep to the overall control total will mean no transformation funding from NHSE for the entire system. In effect, each provider will police the spending of its partners. As, increasingly, many providers within ICOs or ICSs could be private companies whose first priority must be to make a profit, they are unlikely to put aside their own interests for the good of the whole, especially as some NHS providers will be in deficit. Alternatively, this system runs the risk that public funding will be used to support private companies operating at a loss.
There are indications that one of the ways in which an ICS or ICO will reduce costs will be through ‘transforming’ its workforce. As the private consultancy firm McKinsey (2009) points out, STP plans, “provider efficiencies” are the biggest way to cut costs. With staffing the biggest cost for providers, the new set ups are likely to have reduced numbers of doctors and nurses. Instead, new digital technologies will be introduced, and new roles, such as lower paid, lower skilled physician- and nurse-associates. It ‘s feared that nationally agreed pay levels and NHS terms and conditions of work will be undermined as members of staff are transferred to employment by ICOs and offered locally negotiated employment contracts.
New systems for delivering care, like ICOs and ICSs, are being introduced at breakneck speed, without robust evidence, and in the absence of meaningful public involvement and consultation, parliamentary scrutiny or appropriate legislation. In addition, they are already beginning to allow private corporations new roles and powers to shape the NHS in their interests.
No one can deny the need for acute, primary care and community NHS services and social care to be fully coordinated. However, this will not be achieved by fragmenting the NHS. Nor does coordination require commercial contracts and the involvement of corporates. The introduction of new care delivery systems such as ICSs and ICOs must be opposed.
Instead, as campaigners such as Keep Our NHD Public argue, the success of a truly coordinated system of health and social care requires:
- Increased funding of the NHS and personal social care to ensure that coordination can deliver improved patient services rather than be the disguise for ‘efficiency savings’ and cuts;
- Personal social care provided on the same terms as health, free at the point of use and paid for from public funding, as in Scotland;
- Full public involvement and meaningful consultation;
- Robust piloting of future plans for coordination with in-depth, independent evaluation;
- Clarity on the governance and accountability of decision making bodies;
- New legislation that
- protects Bevan’s founding principles of the NHS;
- ends the marketisation and fragmentation of the NHS; and
- re-establishes public bodies and NHS services that are accountable to Parliamentand local communities.