Jan Savage explains that Integrated Care Systems mean systematic privatisation of the NHS

There was much delight recently when media coverage of a Government white paper (Integration and innovation: Working together to improve health and social care for all) suggested this marked the end of competition and less private sector involvement in the NHS. In reality, it means quite the reverse.

The white paper is a prelude to an NHS bill due to be laid before Parliament soon with remarkably little opportunity for scrutiny or debate. Its proposals suggest a raft of changes to the NHS carried out in the name of ‘integrated care’, an approach epitomised by what are now called Integrated Care Systems (ICSs).

Background

No one is arguing against the seamless integration of patient care. However, in the context of NHSE restructuring, ‘integrated care’ has little to do with patients’ experience of care. Rather, it’s an idea that can be traced back to a World Economic Forum (WEF) project in 2012/13 that considered the sustainability of publicly provided health services that were facing “a growing burden of disease” and “raised patient expectations”. The project’s report called for governments to take a step back from providing health services and allow the private sector a larger role. It argued that sustainability means cutting high cost services (such as hospital care) and rolling out new payment systems that induce providers to make savings. Moreover, it means raising the productivity of health delivery systems by introducing new models of care that manage ‘demand’ more efficiently while encouraging patients to ‘self-care’.

Significantly, membership of the WEF initiative was dominated by senior delegates from corporations such as McKinsey and, notably, the US giant, UnitedHealth, represented by Simon Stevens. At the time, Stevens was president of UnitedHealth’s global health businesses, but very shortly afterwards he became the head of NHSE. Once in charge of the NHS, he quickly drew up plans echoing many of the WEF’s recommendations, especially those for ‘integrated care’.

Stevens’s first move towards integration was to fragment the NHS in England into 44 local health economies initially called Sustainability and Transformation Partnerships (STPs), and then Accountable Care Systems. These are now in the process of morphing into 42 ICSs.

Integrated Care Systems

According to NHSE, ICSs bring NHS organisations, local authorities and ‘others’ together to work in partnership and take collective responsibility for managing resources. One of an ICS’s key roles is to control the performance, especially the financial performance, of all the partners within it. They will have a capitated budget (a single budget calculated per head of population), and rely on the extensive use of population–level data to identify and focus on high-risk groups while more generally emphasising ill-health prevention and self-care.

NHSE’s introduction of ICSs has raised a number of concerns that are accentuated by the white paper’s proposals. For example, they suggest a shift from fundamental NHS principles towards a delivery system based on what’s ‘good’ for a particular population. In addition, it’s feared that ICSs will increase not just the presence but also the influence of the private sector within the NHS.

ICSs and privatisation

The white paper sets out a new management structure, requiring each ICS to set up two statutory bodies. One of these (the ICS NHS Body) is responsible for the ICS’s strategic direction and for developing a plan to address the health needs of the ICS’s population. The other (the Health and Care Partnership) is responsible for planning and overseeing local services. The members of both of these bodies will be drawn from the NHS, local authorities and ‘others’ who are to be determined locally. These ‘others’ may include representatives from private corporations. In other words, ICSs could enable private companies to have unprecedented influence in shaping which health services are delivered, where and by whom.

With their emphasis on population health, ICSs will be heavily dependent on a wide range of digital services for the collection and analysis of vast data sets. ICSs are expected to procure these services, along with others for the development and management of the ICS itself, from the Health Systems Support Framework (HSSF). This framework lists a range of services (for example, those for risk stratification, demand management and ‘patient engagement and activation’ – a cryptic reference to self-care), together with the organisations that NHSE has accredited to provide these. The HSSF currently lists over 80 such organisations, the majority of which are private corporations like McKinsey, Deloitte and Centene. These companies will be playing an increasingly substantial role within each ICS, as well as having unprecedented access to confidential patient records.

As for the end of competition, the white paper proposes revoking Section 75 of the notorious Health and Social Care Act of 2012, together with the associated Regulations that enforced competition in the NHS. However, this will do nothing to end the marketisation of the NHS. Instead it will serve to turn a regulated market into an unregulated one, without environmental, social and labour protections. At the same time, it will allow ICS commissioners to choose whether to award a contract directly to a provider, or use a more formal procurement process.  This is alarming, as it’s been clear during the Covid pandemic how emergency measures to relax procurement regulations have led to a rapid rise in corruption and cronyism.

The future of the NHS looks bleak, unless there is strong opposition to the legislation foreshadowed by this white paper.

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