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The issue is not just about the merits or demerits of the Integrated Care Provider contract - although we have clear views about that. It’s about whether it is right to “take politics out of the NHS” and make its governance subject to technocratic rather than democratic control.
This is what the likes of Norman Lamb, Sarah Wollaston and others want, those who keep going on about “stopping the NHS being a political football”.
But the NHS is a public service - and a key one at that. It’s vital that it is democratically run. It is too important to be the plaything of unelected quango officials and their similarly unelected underlings in charge of local NHS Integrated Care Systems.
As NHS Defenders told their West Yorkshire and Harrogate Joint Health and Overview Scrutiny Committee, we need to know who has power in Integrated Care Systems, what they’re doing with this power - and how we get rid of them if they abuse it.
The Department of Health’s technocratic “stakeholder” consultation
on the regulatory updates contained in the Statutory Instrument (SI)
Although it’s sidestepping any consultation with Parliament, the Dept of Health carried out a consultation on the proposed regulatory changes in Autumn 2017.
They published their response to this consultation in April 2018.
In Oct-Dec 2018, the Dept of Health carried out a a “technical consultation for GPs and others involved in the provision of primary medical services”, about the proposed Directions to NHS England on primary care services in an Integrated Care Provider contract.
These Directions spell out key aspects of the content of the Integrated Provider Contract, and so underpin the Statutory Instrument snuck out by the government on 13th February.
Our quick straw poll of GPs found they’d not heard of this GPs’ consultation - suggesting that the Department of Health didn’t go out of their way to publicise it.
NHSE also included a draft of the Directions in the Integrated Care Provider Contract Consultation package. The ICP contract consultation was held Aug- Oct 2018. It was incredibly poorly publicised and so received very few responses.
Integrated Care Provider Contract directions for primary care services
are based on directions for Alternative Provider of Medical Services (APMS) contracts
It looks as if the Directions mean ANYONE can enter an Integrated Care Provider contract to provide GP services.
APMS contracts were introduced by the New Labour government in 2004, to open up primary care to ‘new providers’. They used to procure the New Labour government’s ill-fated ‘Darzi’ centres across the country.
A 2009 GP Magazine article says:
“APMS contracts are the private sector's gateway to providing primary health care to NHS patients.”
They don’t require a GP practice to be run by medical people, and they are very controllable, time limited and driven by Key Performance Indicators (KPIs).
The Integrated Care Provider Contract Directions explicitly OMIT the Alternative Provider of Medical Services directions that list those who are ineligible to hold an APMS contract, and that require NHS England to make sure that no one who is ineligible to hold an APMS contract, enters into one.
Instead those directions are now replaced by an Integrated Care Provider direction that says:
"Under the ICP arrangements, primary medical services would be provided as part of the wider contract. As such, it would not be appropriate to apply preconditions appropriate to individual performers of primary medical services."
Are we right to read that as meaning NO ONE is ineligible to enter an ICP contract to provide primary care services? Any private company can apply?
The Integrated Care Provider contract directions for primary care services also says:
"The parties may indicate whether or not the contract is an NHS contract
for the purposes of s9 NHS Act 2006."
And there is a contract dispute resolution direction that talks about what process should be used where it’s not an NHS contract. (see Briefing Doc for full info)
This sort of detail is important. It’s worth remembering that Centene UK, assisted by executives from Ribera Salud (the discredited Spanish subsidiary of the USA Centene Corporation), is looking to acquire primary care and mental health companies in the United Kingdom, according to reports from Valencia Plaza.
Ribera Salud recently appointed the former New Labour Health Secretary Alan Milburn to its Board of Directors, to help it “continue with its expansion plans.” In addition, during the recent visit to Valencia of the United Kingdom’s ambassador to Spain, Simon Manley, a British manager of Ribera Salud contacted him to explain the company’s plans.
To annul NHS Integrated Care Provider legislation that was "quietly introduced" without Parliamentary debate or scrutiny.
We are asking MPs to support National Health Service Early Day Motion #2103 (link below the image). There is a full BRIEFING DOCUMENT to download if you want to full information about the secondary legislation.
Jeremy Corbyn, Jon Ashworth and other MPs are sponsoring a Prayer Motion (National Health Service EDM #2103) that calls for the annulment of a Statutory Instrument - the device used to sneak through legislation with fingers crossed no one will notice. The prayer has to contain the following...
“That an humble Address be presented to Her Majesty, praying that the Amendments Relating to the Provision of Integrated Care Regulations 2019 (S.I., 2019, No. 248), dated 13 February 2019, a copy of which was laid before this House on 13 February 2019, be annulled.”
Prayer Motions are considered by many to be parliamentary ettiquette - but they could be so much more than just a symbolic paper gesture! Getting an Early Day Motion on the table takes teamwork and action!
The Department of Health sees no need to consult with MPs
MPs who represent the people who are going to need to use these GP services.
The 2012 HSCA effectively removed the NHS from democratic control by removing the Secretary of State’s duty to provide or make provision for a comprehensive universal NHS.
It dispersed many of these powers and duties to unelected arms length bodies - quangos - that operate a revolving door between corporations seeking NHS contracts, and the quangos that regulate them. Any democratic control of the NHS is hollowed out by this corporate invasion of its quangos.
The tangled web of technocratic organisations that govern the NHS means it is next to impossible to trace clear information about what is going on.
And withholding information is key to dismantling the NHS, according to a retired Hospital Trust consultant and manager who walked from Jarrow to London on the People’s March for the NHS.
On 28.1.19 Matt Hancock told the House of Commons Health and Social Care Select Committee inquiry into the NHS Long Term Plan that: “The Department of Health is open to potentially making government time available for a bill.”
So why can’t the Department of Health include these proposed amendments to GP contracts in this potential bill? Rather than sneaking them in through a Statutory Instrument?
(for full info and links see Briefing Document)
Why we have to fight the Integrated Care Provider contract
The British Medical Association fear the Statutory Instrument will lead to coercion of GPs to switch over to the Integrated Care Provider contract, which they are not happy with.
The 999 Call for the NHS #Justice4NHS campaign is still challenging the lawfulness of the Integrated Care Provider contract, with our application for permission to appeal to the Supreme Court.
The Statutory Instrument doesn’t mention this - of course.
Our ongoing legal challenge to the Integrated Care Provider contract concerns the lawfulness of the cost cutting payment mechanism in the contract. It’s designed to limit patients' access to healthcare, by introducing financial considerations about return on investment into doctors' decisions about which patients get which treatment.
The result in the USA's Accountable Care Organisations has been denials of care and cherrypicking patients who will be cheapest to treat and will have the best outcomes.
The Integrated Care Provider contract is a Lead Provider contract
and there is no certainty that it will be held by a statutory organisation
The Statutory Instrument reveals the complexity of the Integrated Care Provider contract - meaning that it is intended for one organisation holding the purse and subcontracting over and over again.
The SI continually refers to things like
"the services provided by—
(i) an independent sub-contractor on behalf of an independent provider"
All this rigmarole about independent providers and independent sub contractors surely gives the lie to Appcock's and Stevens' statements to the Health Select Committee on 28.1.19 (which MPs lapped up delightedly) that there would be no privatisation associated with Integrated Care Providers.
The Explanatory Memo to the Statutory Instrument says that it is "expected" that organisations holding an Integrated Care Provider contract will be “statutory providers, such as NHS Foundation Trusts”
- but this is in no way a legally binding commitment.
The government’s press release about the Statutory Instrument tries to support this “expectation” by saying, "Any bids for the contract will be reviewed by local clinicians and NHS staff to ensure it is the most effective and beneficial organisation for the local area."
Well we all know how well that process has gone to date. Not.
Directly contradicting the official spin... the Explanatory Notes to the August 2018 Integrated Care Provider documents specify that a non-statutory body could hold an Integrated Care Provider contract.
They include an “Appendix of Additional/alternative protections where Provider is not a Statutory Body.” These protections include “Permitted Provider Distributions and Dealings in Shares and Membership Interests”.
Changes to GP practices under Integrated Care Systems are not in patients' interests
Basically the Integrated Care RE-DISORGANISATION that NHS England is imposing involves:
Cutting and centralising hospital services.
Moving hospital services into new primary care networks serving 30K-50K patients that each shares a "locality hub" serving up to around 180k patients.
Restricting patients’ access to GPs - who will mostly only see high cost patients with complex conditions while new grades of less qualified staff will see everyone else.
Pushing much of the work of health and social care onto patients themselves, their families, friends and voluntary sector organisations (the so-called “left shift”).
Large scale behaviour changes schemes targeted at patients suffering from or deemed to be at risk of modern epidemics eg obesity, diabetes, anxiety, depression, heart and respiratory problems - regardless that these are largely determined by social, economic and environmental injustices and deregulated corporations.
A lot of remote digital monitoring of people's participation in these behaviour change schemes through wearable technology - with pretty horrendous privacy and civil liberties implications (briefly discussion by Shoshana Zuboff in her Surveillance Capitalism book) and the slippery slope towards conditionality of NHS care.
Even if GPs don’t sign up to be part of Integrated Care Providers, where local Commissioners are introducing this contract, they can be “partially integrated” into an Integrated Care Provider contract through signing an Integration Agreement.
And NHS England has another contract that forces them to provide the same model of primary and community health care that the Integrated Care Providers will deliver. This is the new GPs Primary Care Network Contract - formerly known as a Virtual Accountable Care Organisation/Integrated Care Provider contract.
Like the Integrated Care Provider contract, the new GP Primary Care Network Contract - or virtual Integrated Care Provider contract - is a form of lead provider contract.
The differences are that:
It is likely that the lead provider for the GP Primary Care Network Contract will be a GP Federation or GP-led organisation.
It does not require GPs to suspend or abandon their existing contracts. It sits on top of those contracts.
One way or another, the Department of Health and NHS England are intent on ramming through this massive change to the way GPs work. But we should not allow them to sneak this past MPs, without them having the chance of debating its merits and the effects it will have on the public.