NHS England has now published an exhausting list of requirements for local provider trusts, CCGs and embryonic “Integrated Care Systems,” (ICSs) setting them on a route march to a bizarre form of “integration”.
The NHS England vision for integrated care is that the NHS be split into three main levels: neighbourhood (30,000-50,000 population), “place” (250,000-500,000) and “system” (1 million to 3 million), with NHS England and NHS Improvement controlling the whole set-up at regional and national level.
To do this they need to effectively disregard (or persuade government to change) the existing legislation – forced through by the Tory-LibDem coalition in the Health and Social Care Act 2012 – which carved England’s NHS up into a market consisting of local commissioners (200+ CCGs) holding the purse strings, and providers (NHS Trusts, Foundation trusts and GPs, private – for-profit and non-profit – and voluntary sector.)
The 2012 legislation abolished the previous wider local structures (100+ Primary Care Trusts) and regional bodies (Strategic Health Authorities): now NHS England is seeking to put together a new version – so without any statutory powers or legal standing, and without any accountability or transparency at local level.
They are driving the mergers of CCGs, with 56 set to disappear in a new round of mergers from April, leaving just 135 (with more mergers planned), and reorganisation of services into 42 Sustainability and Transformation Partnership (STP) areas, which according to NHS Improvement’s chief operation officer are expected to develop into ICSs by April 2021.
The NHS Operation planning and Contracting Guidance 2020/21 is the latest step towards establishing NHS England’s plan: it is only 40 pages long, but densely packed, with each page studded with extra demands on local health bosses.
The common factor running through all the demands on local commissioners and providers is NHS England’s determination to force them into “Integrated Care Systems” – despite the absence of any legal powers or legitimacy for such bodies to be established, and therefore little if any public accountability for their actions.
No public involvement
There is no mention of public involvement, engagement – or indeed of the public at all, except as the recipients of services commissioned and decided by local health systems. Instead the Introduction claims that the NHS has since last year been in a period of “stability” with the limits of its funding now set in law up to 2024:
“The NHS and its partners have used this stability to develop local system-wide strategic plans during 2019 that will put the NHS on a sustainable financial footing whilst expanding and improving the services and care it provides patients and the public.”
This same blinkered approach – ignoring manifest and major problems – means NHS England makes no reference to the changes they want made to the law, which were outlined in the Long Term Plan and spelled out in more detail during last year.
The Guidance gives no indication of any concern at the lack of commitment of the Johnson government to honour its manifesto pledge to pass the necessary legislation to give ICSs legal standing, and to lift the current legal requirement on CCGs to carve local services into a series of contracts to be put out to competitive tender.
It now seems, according to carefully leaked rumours headlined in the Times, Telegraph, Daily Mail and Independent, that the legislation when passed will include new powers for ministers (and of course Johnson’s Downing Street Svengali Dominic Cummings) to give orders to NHS England’s boss, the freshly-knighted Simon Stevens.
The Times reports concerns of health chiefs who fear this could amount to a fresh reorganisation of the NHS. Campaigners will fear it will assert centralised control while not fully repealing the 2012 Health and Social Care Act that entrenched a costly and divisive “market” in health care.
The Planning Guidance indicates NHS England is forging ahead as if they already had their preferred version of a more centralised system in place, and spells out ways in which commissioners and providers in 42 STP areas are increasingly required to work together as a single “system”.
Section 2.1 of the Guidance makes clear that ALL systems are expected to agree five separate arrangements with NHS England’s regional directors which are key to them progressing to ICSs:
- a leadership model for the system, “including a Sustainability and Transformation Partnership (STP)/ ICS leader with sufficient capacity”….
- system capabilities “including population health management, service redesign, workforce transformation, and digitisation” ….
- agreed ways of working across the system in respect of “financial governance and collaboration” …
- streamlining commissioning arrangements, “including typically one CCG per system”
- capital and estates plans at a system level… .
These are to ensure ICSs can carry out two “core roles”: system transformation and collective management of system performance (pulling individual trusts into line).
System planning
Section 2.2 of the Guidance is on “system planning”, again focused on ensuring that every commissioner and provider each of the 42 systems is tied in with “local strategic plans” (few of which have yet been published). In other words the plan is to override the existing (limited) local accountability and existing statutory responsibilities of trusts and CCGs.
Section 3 sets out a tough assault course of performance targets which systems are expected to achieve. In Primary Care a tokenistic carrot of £45m of development funding is to be shared between 42 systems, while the stick includes requirements to invest in extra staff (the unfortunately named ARRS scheme (Additional Roles Reimbursement Scheme), extra doctors, delivering reductions in long waits for routine appointments, and “full delivery of online consultation systems” (whether patients want them or not).
Community health services, with little if any extra resource are required to work to deliver “crisis response services within two hours of referral, and reablement care within two days of referral to those patients who are judged to need it” – although no details are published on how far away they are from that target, or where they are supposed to find staff and funding.
On mental health (3.2) the Guidance refers to (but does not reproduce) over a dozen rigorous “deliverables” to improve performance, despite the fact that the 135 CCGs that will exist from April have to share out a measly £135m “Long Term Plan baseline funding to bolster community mental health provision,” and will get back only 40% of the salary costs of the additional trainees they will need to expand IAPT services.
On learning disabilities (3.3) along with a series of vague commitments to “ensure there is the right range of support and care services in the community”, and to “increased use of Personal Health Budgets”, there is a requirement to visit adult inpatients in out of area placements every 8 weeks, and children every 6 weeks – hardly inspiring for those fearful these patients will be largely neglected and forgotten.
On urgent and emergency care (3.4) there is a historic shift away from three decades of efforts to reduce front line bed numbers:
“systems and organisations will be expected to reduce general and acute bed occupancy levels to a maximum of 92%. This means that the long period of reducing the number of beds across the NHS should not be expected to continue. …
“The default operational assumption is that the peak of open bed capacity achieved through the winter of 2019/20 will be at least maintained through 2020/21, including the 3,000 increase from October 2019 already planned for.”
Credible plans
It appears that the onus is now on those seeking to reduce bed numbers, or increase by a lower amount, to produce “Credible plans to release capacity through reductions in length of stay, improvements in Delayed Transfers of Care (DTOCs), and admission avoidance programmes”. But we have heard similar before from NHS England, without any let-up in the run-down of bed numbers.
Despite recent warnings on lack of capacity from the Royal College of Emergency Medicine and the Society of Acute Medicine, there is an ambitious target to increase “same day emergency care” by September, and 65% delivering acute frailty services.
And as trusts implement plans to institutionalise it, with corridor nurses and paramedics, NHS England is demanding measures to avoid ambulance delays and “eliminate corridor care”.
“Waiting lists should be lower”
More ambitious still are the demands on elective care (3.5): “Specifically, the waiting list on 31 January 2021 should be lower than that at 31 January 2020. …
“Providers should ensure appropriate planning and profiling of elective and non-elective activity throughout the year, taking into consideration expected peaks in non-elective performance over winter months in order to avoid risk of unplanned cancellations.
“Waits of 52 weeks or more for treatment should be eradicated.”
So easy to say, so hard to do without sufficient beds, staff, capital or revenue. Indeed if it was that easy it would already have been done.
Similarly fanciful demands follow for changes to outpatient services (3.6), reduced waits for cancer treatment (3.7), and an even more unrealistic section on public health (3.8), which simply piles on more tasks and targets without giving any baseline figures on the current state of play, discussing the cuts in funding that have been made, or identifying any additional resources.
The “People” plan (Section 4) continues the theme of wishful thinking, though it does note that the infamous promise of 50,000 extra nurses is to be delivered “by 2025,” (together with 6,000 more doctors working in primary care and a 26,000 increase in the wider primary care workforce).
The credibility of the proposals is not enhanced by the focus on “a significant expansion of ethical international recruitment of high-quality nurses, driven by a new national programme which will be established early in 2020.”
Government erecting barriers
It appears nobody in NHS England has noticed the government’s efforts to deter immigration of anyone earning less than £30,000 a year, and the associated hefty upfront costs of even the discounted NHS visa and the commitment to jack up the annual “Immigration Health Surcharge” to £625 per year.
But then the Planning Guidance appears to be more of a wish list than a check list, not so much blue skies thinking as cloud cuckoo land. Only the strings and financial penalties are real – and the extent to which these can make trusts and commissioners jump through NHS England’s hoops remains to be seen.
Whether any of this can meaningfully be called “integration” is another question.
The test is in the financial discipline. While the HSJ has reported the “unprecedented” decision of the merging CCGs in Norfolk and Waveney to chip in with financial support “to help two acute trusts agree control totals”, The Lowdown waits with interest to see the first trust or foundation trust running a surplus that is willing to part with some or all of it in order to ensure a local system including trusts in deficit can meet its control total.
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