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Our response to NHS England’s consultation on ICPs

1. Should local commissioners and providers have the option of a contract that promotes the integration of the full range of health, and where appropriate, care services?

Should local commissioners and providers have the option of a contract that promotes the integration of the full range of health, and where appropriate, care services?:

No

Please explain your response. :

Health and social care working together is clear a good idea and could benefit patients but it is not clear that a block contract is the only, or the most appropriate, way to do this. The root cause of the increase in fragmentation of the health service over recent years is the emphasis on the market and competitive tendering rather than collaboration and appropriate planning to meet care needs. The market mechanisms which have led to fragmentation are not removed in this new model, merely shifted a layer down from the CCG to the ICP which then subcontracts to providers.

There are too many unanswered questions: currently social care is means tested and mostly privately provided whereas healthcare is free at the point of use and mostly publicly provided. There is a risk that this integration will lead to health becoming more like social care which is currently failing to provide for all those who need it rather than vice versa.

There is no guarantee that these contracts will be awarded within the public sector. If they are awarded in the commercial sector there is a significant risk of provider failure (cf Circle at Hinchingbrooke, Carillion) which will put patients' lives and wellbeing at risk.

It is unclear what transparency and public accountability will operate in ICP. Currently it is possible to hold our CCGs to account for the services delivered but it is unclear what mechanisms will exist. Legislation to end contracting and renationalise the NHS in England is needed in order to promote genuine integration between health and social care. Social care must be publicly funded and publicly provided on an equal footing with healthcare.

 2. The draft ICP Contract contains new content aimed at promoting integration, including:

Should these specific elements be amended and if so how exactly?:

No

Please explain your response. :

They should not be amended, they should be scrapped.

These proposals will be disastrous for General Practice and for patients everywhere. General practice built on a partnership model has, until recently, been the jewel in the crown of the NHS, delivering personalised, local medical services and ensuring continuity of care which is proven to be cost effective and to improve health outcomes. The dissolution of traditional partnerships and their absorption into larger ICPs is likely to lead to less personal care and less continuity of care.

Apart from responding to this consultation, will patients have any say in how their services are reorganised? The movement away from independent, local and responsive practices is likely to be extremely unpopular.

There is lack of clarity about how and to whom 'place-based' services will be provided. Currently GPs often have patients living in areas covered by more than one local authority. It is not clear how the ICP will serve patients from all the participating practices and also work with local authority areas as these are not co-terminus.

General Practice is struggling through lack of funding and workload pressures. Absorption into ICPs is unlikely to be a effective or popular solution.

Are there any additional requirements which should be included in the national content of the draft ICP Contract to promote integration of services?:

Yes

 Please explain your response.:

If this does proceed, there should be a requirement that the provider is a publicly owned NHS body. This is the only way that we will ensure that resources are dedicated to improving the health and well-being of the population.

This would clearly require legal changes, but the concept that a such huge reconfiguration of healthcare should proceed without primary legislation is inappropriate anyway.

This new contracting model is unlikely to improve patients' experience of care. The barriers to integration at present are partly related to lack of funding, understaffing and hopeless failures of IT. There is a structural problem related to different funding mechanisms for health and social care, but this should be solved by adequate public funding and provision of social care rather than contractual changes.

 3. The draft ICP Contract is designed to be used as a national framework, incorporating core requirements and processes. It is for local commissioners to determine matters such as:

 Have we struck the right balance in the draft ICP Contract between the national content setting out requirements for providers, and the content about providers’ obligations to be determined by local commissioners?:

No

Please explain your response.:

This is a recipe for worsening post-code lotteries in health care.

Clearly commissioners of health care should ensure that services are adequate to meeting the specific needs of their population and that might mean extra services for problems which are more prevalent in an area. However, in the current context of financial stringency local decision making about what services to provide runs the risk of service cuts and closures. Already different STP areas are cutting services in different ways and this will be even worse with ICPs which an even stronger financial incentive to restrict services. This is fundamentally wrong and undermines the NHS principles of universal comprehensive care, and our rights under the NHS constitution. ICPs, which will inevitably be less transparent or accountable, should not be allowed to make decisions about service cuts, closures or reconfigurations.

The consultation document says that commissioners will employ “light touch” oversight of what services the ICP is providing and how it is providing them. That contradicts other statements that the commissioners will be very involved in scrutinising the ICP and its subcontractor’s performance and holding them to account.

The public can have no confidence in a “light touch” approach to regulating such a vital high-risk contract and it is shocking that this is even being suggested.

4. Does the bringing together of different funding streams into a single budget provide a useful flexibility for providers?

No

Please explain your response.:

This would certainly be flexible but will also be extraordinarily risky, especially if the contract is awarded to a private provider. This would involve giving the entire budget for a region's health and social care to organisations that are not part of the NHS and therefore not statutory accountable public bodies, which seems unwise.

 5. We have set out how the ICP Contract contains provisions to:

 Do you agree or disagree with our proposal that these specific safeguards should be included?:

Disagree

 Please explain your response.:

These guarantees and safeguards do not fill us with confidence. There are no contractual “safeguards” that will mitigate the lack of transparency or accountability inherent in ICPs.

NHS England cannot credibly argue that creating another layer of bureaucracy and removing direct responsibility for planning and delivery of health from statutory organisations to non-statutory organisations, would enhance transparency and accountability.

Although it is not clear what role CCGs will play in the future, currently it is proposed that all of the public duties of transparency and accountability would be mediated through the CCG, such as responding to Freedom of Information requests. ICPs would not be directly subject to FOI law. The CCGs themselves have not proved to be very transparent or accountable and having their duties mediated through a lead provider/subcontractor model will make it even more remote, opaque and difficult for the public to be able to scrutinise or hold to account.

The ICP would be able to hide behind “commercial confidentiality” to deny the public access to information. ICPs may not be subject to judicial review or human rights challenges. It is also unclear what rights local government scrutiny committees would have to scrutinise the ICP and hold it to account.

Do you have any specific suggestions for additional requirements, consistent with the current legal framework, and if so what are they?:

No

 Please explain your response.:

If the legal framework dictates that the only way to have better integration of care is through contracting then the legal framework has to change. Contracting should be abolished as a way of arranging health care in England. The Scottish, Welsh and Northern Irish health care systems are not based on a contracting model, it is clearly possible to plan and deliver health services without using contracting.

What is needed is legislation to renationalise the NHS in England.

It is worth noting that administrative costs as a percentage of overall spending on health care were very much lower before the mechanisms of the market were introduced.

 Consultation questions

6. Should we create a means for GPs to integrate their services with ICPs, whilst continuing to operate under their existing primary care contracts?

Should we create a means for GPs to integrate their services with ICPs, whilst continuing to operate under their existing primary care contracts?:

No

Please explain your response.:

Given there is a high risk that ICPs will be a vehicle for further reduction and privatisation of NHS services, it would seem unwise for GPs to be involved. GPs already provide integrated care working with community nursing and social services, but are hampered by lack of funds and staff.

 If yes, how exactly do you think we should create this?:

Are there any specific features of the proposed options for GP participation in ICPs that could be improved?:

No

Please explain your response.:

The proposal is deeply unattractive. The only reason that a GP might choose to participate is because current practice is made nonviable.

There is no appetite to be subsumed into a huge organisation and lose independence and local connections. GPs are well able to work in an integrated fashion with other services. if time is made available for team coordination and multidisciplinary meetings.

7. Do you think that the draft ICP Contract adequately provides for the inclusion of local authority services (public health services and social care) within a broader set of integrated health and care services?

Do you think that the draft ICP Contract adequately provides for the inclusion of local authority services (public health services and social care) within a broader set of integrated health and care services?:

No

Please explain your response:

1 - Health care is free and social care is means tested and charged for. This is one of the main impediments to integration of health and social care. Greater integration of health and social care, without addressing the fundamental entitlement issue, will enlarge the scope for redefining some health care as social care and facilitate the increased transfer of funding obligations from the state to the individual.

2 - It is vital to consider any plans to integrate health and social care within the pressing context of what is happening to social care. The CQC “state of care” report in 2017 said that “the future of care for older people is one of the greatest unresolved public policy issues of our time”. The draft ICP has nothing to offer to resolve this. The public and NHS and social care staff will not respect attempted solutions that don’t address the real and urgent problems facing health and social care. Anything else is a waste of time.

3 - Public health is also in a grave condition. In 2012 Public Health was handed over to local authorities and immediately cut. Every year more community and public health services have been cut. It is not credible to suggest that a new kind of contract will miraculously provide resources for public health from thin air. Either the government funds public health properly or it does not. The ICP contract will make no difference to that reality.

If not, what specifically do you propose?:

Nationalise social care as a National Care Service, free at the point of use. Re-Nationalise the NHS.

Fully integrate The National Care Service with the NHS. Fund health and social care adequately, at least matching our G7 counterparts. Fund public health adequately, reversing the cuts forced on it by local authority cuts. Improve pay, working conditions and training for carers so that it becomes an attractive job where people have the time and skills to care for their clients well and feel rewarded for their dedication.

8. The draft ICP Contract includes safeguards designed to help contracting parties to ensure commissioners' statutory duties are not unlawfully delegated to an ICP:

Are there any other specific safeguards we should include to help the parties to ensure commissioners’ statutory duties are not unlawfully delegated to an ICP?:

Yes

Please explain your response.:

It makes no sense to say that a safeguard against unlawful delegation is simply to have a phrase in the contract to say there can be no unlawful delegation. That is a circular argument. At best there will be a duplication of work if the CCGs still have the same statutory duties, but the ICPs also have to carry out and support those duties, and the CCGs job is to ensure the ICP fulfils those duties.

In reality there is likely to be confusion about lines of accountability and lack of transparency, with patients and public left with little clarity about what is really going on.

Instead we suggest:

(1) drop the proposals for ICPs,

(2) halt any further contracting out of services

(3) keep services under the control of statutory, public bodies with established lines of accountability.

(4) Revise the constitutions of CCGs to create a new duty to collaborate with local

NHS providers to plan and provide services pending legislation to abolish the purchaser/provider split.

9. The draft ICP Contract includes specific provisions, replicating those contained in the generic NHS Standard Contract, aimed at ensuring public accountability, including: Should we include much the same obligations in the ICP Contract on these matters as under the generic NHS Standard Contract?:

No

 Please explain your response.:

Even if the ICP contract has the same obligations as under the generic NHS Standard Contract the ICP’s public accountability will not be direct but will be mediated through the CCG. The public will have to rely on the skills and willingness of the CCGs to hold ICPs to account. Based on previous experience of poor contract management and enforcement, there is little basis for confidence that CCGs would have the necessary staff, skills or willingness to rigorously and robustly manage the ICP contracts. Such a major provider of health and social care would be “too big to fail”, so it is hard to see the CCG ever terminating the contract, even if performing badly. CCGs will be afraid that private providers will sue them if they try to enforce the contract in a way that the provider disagrees with, or terminate the contract, as we have seen happening already (Virgin).

The draft ICP contract refers to the ICP “involving” and “engaging” the public but this is not defined and could easily be fulfilled by minimal levels of involvement or engagement. There is little assurance in hearing that the Friends and Family test will apply as it is a weak and poorly discriminating tool. Likewise, complaints procedures, while important, are unlikely to be much use in holding a huge contract to account. The duty of candour only applies once things have gone wrong, which is too late.

The duty of candour is not a reliable instrument for quality, transparency or accountability as many staff are still too afraid to speak out about unsafe or poor quality working conditions.

Do you have any additional, specific suggestions to ensure current public accountability arrangements are maintained and enhanced through an ICP Contract?:

Yes

Please explain your response.:

Award ICP contracts exclusively to NHS bodies.

As ICP contracts could be with non-NHS bodies they will not be subject to statutory obligations for consultation and accountability. It is the ICP concept itself that militates against public accountability. No body that is not a public statutory body can have better accountability than a public statutory body, and contract clauses cannot make up for that shortcoming. The only way to make ICPs fully publicly accountable is to make them NHS public bodies.

10. It is our intention to hold ICPs to a higher standard of transparency on value, quality and effectiveness, and to reduce inappropriate clinical variation. In order to achieve this the draft ICP Contract builds on existing NHS standards by incorporating additional provisions describing the core features of a whole population model of care and new requirements relating to financial control and transparency:

Do you think that the draft ICP Contract allows ICPs to be held to a higher standard of value, quality and effectiveness and to reduce inappropriate clinical variation?:

No

Please explain your response:

The draft ICP contract particulars on quality requirements have the same quality requirements as in the NHS standard contract.

These quality requirements have nothing to do with quality but are financial penalties for failure to reach certain delivery targets. But the experience of the NHS standard contract is that this punitive approach to quality has failed, so there is no reason to believe it will function any better in an ICP contract.

The other references to enhancing quality are just words and phrases like “seamless care” with nothing about how they will actually happen. Such ideals are meaningless without the resources to back them up.

The Friends and Family tests is mentioned again in this context, but evaluation of the test has shown it to be largely ineffective in improving quality.

In conclusion, there is nothing in the draft ICP contract that indicates it will be held to a higher standard of value, quality and effectiveness than current contracts.

And even if there are various aspirations written in to the contract there is no reason to believe they will make any difference in the real world, where the factors affecting quality are understaffing and underfunding. The ICP contract does not address education and training of health care personnel. We need a national workforce strategy, but there is no reference in the ICP contract to it having any responsibility for training the workforce within an overall national strategy.

Do you have any additional, specific suggestions to secure improved value, quality and effectiveness, and reduce inappropriate clinical variation?:

Yes

Please explain your response:

The problems in the health service are related to inadequate funding and maldistribution of funds. We need to accept that quality and effectiveness are not problems that can be solved by a new kind of contract and focus instead on the real causes of failings in the NHS and social care. Then, in genuine collaboration with NHS staff and patients, come up with solutions which are likely to work. If that requires extra funding, more staff, other resources, or changes to legislation then NHS England should be putting its energies into making the appropriate case to the government, not wasting its time devising new contract forms that fail to address the real issues.

The current ICP proposal looks set to worsen clinical variation and there has been no evidence presented that it will improve value, quality or effectiveness.

11. In addition to the areas covered above, do you have any other suggestions for specific changes to the draft ICP Contract, or for avoiding, reducing or compensating for any impacts that introducing this Contract may have?

In addition to the areas covered above, do you have any other suggestions for specific changes to the draft ICP Contract, or for avoiding, reducing or compensating for any impacts that introducing this Contract may have?:

Yes

Please explain your response. :

Abandon the ICP contract. The ICP contract is dangerous and ill conceived. It will not solve the problems it seeks to address while creating a whole new set of problems, risks and costs, including the risk of increased privatisation.

Integrated care is a worthy aim but the ICP contract is not the way to achieve it. The only way to get genuinely integrated care is through primary legislation to recreate statutory local health authorities with the power to plan and deliver services, working closely with staff and patients. Fundamentally this will require legislation to renationalise the English NHS.

As a society we need urgently to address the issue of social care and either create a national care service along the lines of the NHS, or incorporate social care into the NHS.

Primary, secondary, community and mental health care all need substantially more staffing and funding in order to work safely and well and to work in a more integrated way. NHSE must make the case to government for these changes and not waste more time and resources on promoting the ICP contract.

12. Are there any specific equality and health inequalities impacts not covered by our assessment that arise from the national provisions within the draft ICP Contract?

Are there any specific equality and health inequalities impacts not covered by our assessment that arise from the national provisions within the draft ICP Contract?:

Yes

Please explain your response. :

Health inequalities cannot be reduced without tackling the massive social inequalities in our society.

We are one of the most unequal societies in Europe and have some of the worst health outcomes for that reason. Our children’s health is among the worst in Europe. Life expectancy has started to fall for the first time in decades. Infant mortality rates are rising. The class differences in health outcomes have not shifted. Austerity is taking its toll on people’s mental and physical health. Public health has been decimated.

It is unrealistic to suggest that a new kind of contract will reduce health inequalities, especially when other organisations with this remit, such as CCGs, have failed. The fundamental reasons for health inequalities need to be addressed and the ICP contract can’t and won’t do that. If NHSE wants to reduce health inequalities it needs to promote and lobby for policies that address the social determinants of health, in particular an end to austerity.