How can this Report be independent when you read the identity of two of the three special advisers, and find in footnote 10, the conflict of interest declaration for Chris Ham & Anna Charles (both employed by the Kings Fund)? Ham says:
“The Kings Fund is working to support accountable care systems in England and some of the funding for this work has been provided by NHSE. Our work on STPs was funded entirely by the Kings Fund.”
“The Kings Fund is providing support to accountable care systems in England. This work has been partly funded by NHSE. Our work on STPs was funded by the Kings Fund.”
Last winter, NHS Detectives warned of Kings Fund fingers in the Health Select Committee Inquiry’s pie, when we found that the House of Commons briefing on Accountable Care Organisations was heavily dependent on the Kings Fund think tank for a summary of the core features of Accountable Care Organisations.
We pointed out that the Kings Fund is far from impartial in its views on Accountable Care Organisations and their variants, Accountable Care Systems and Partnerships.
So it should be no surprise that this Report is shockingly biassed – although coated in Establishment Fudge. The Report’s rhetorical strategy is to admit some facts that challenge their view (providing a defence against accusations of bias), then equivocate and cast doubt on them, before omitting them from their Conclusions and Recommendations.
It also pulls off quite a clever trick. It doesn’t recommend that the government abandons any of its key Accountable Care ambitions, but the Report does rap the quangos over the knuckles for the way it has directed the moves towards Accountable Care. This simultaneously avoids alienating Tories (because the mud is not thrown at their Sec of State), and makes enough criticisms that may well persuade some people of other political persuasions who oppose Accountable Care, that their arguments have been taken on board.
The establishment of a cross-party consensus on how to move Accountable Care forward was Sarah Wollaston’s stated aim well before the Inquiry into Integrated Care: Organisations, Partnerships and Systems. The Report gallops in hot pursuit of this goal.
The masters’ voice
Rather than seriously examine the claims made by both proponents and opponents of Accountable Care, the Report gives unquestioning credence to “leaders” and dismisses campaigners’ “projected fears” which “are making the challenge of integrating care more difficult.”
For instance, it quotes the Chief Executive of the NHS Confederation – the trade body that represents the interests of private companies in the NHS alongside NHS providers. Niall Dickinson dismisses campaigners’ concerns that Sustainability and Transformation Plans would increase NHS privatisation as “palpable nonsense” that has “certainly tainted the brand.”
But would MPs have even held this Inquiry, if NHS campaign groups had not first drawn the attention of the public and politicians to the issues that the Health and Social Care Select Committee have investigated?
NHS campaign groups “play on the public’s genuine concerns”
According to the Report, NHS campaign groups are the frequent source of “ inaccurate, misleading” messages that “play on the public’s genuine concerns.” As if we are not the public and our concerns are not genuine – nor based on sound evidence.
More than once they assert that we are “projecting” fears of NHS privatisation onto changes in health policy. We’re not.
Projection is a mechanism for someone to disavow things about themselves that they can’t bear to accept, and to blame them on someone else. Use of the word projection implies that there are no reasonable grounds for fears of NHS privatisation, but that they are simply the product of the imagination of people who don’t know their own minds.
What about the projections of politicians who disavow the existence of NHS privatisation policies over the last three or four decades, and fail to interrogate current changes in health policy to see if they ride on this privatisation policy tide?
The Report endorses what the Dept of Health and NHS England seem to have already decided
This is to sidestep Accountable Care Organisations, and promote Integrated Care Systems and the Primary Care Home model, at least for now.
The Report is cheerleading for this decision that the Dept of Health and its quangos pretty clearly made some months ago, when they saw which way the political and campaigners’ wind was blowing.
I don’t think it solves the problems of Accountable Care – far from it. Because, although the Report denies this, it still means the import into the NHS of US contract and payment methods, new less qualified workforce grades whose introduction deskills clinicians, and care models that open the door wide to privatisation.
Not through handing a big contract to a single provider to subcontract out (although there will be plenty of that I reckon anyway – the Yorkshire and Humber Integrated Urgent Care Service looks like just such a beast), but through Recommendation 17 that Accountable Care Organisations should have the freedom to involve, and contract with, non-statutory bodies.
This would prop the door wide open to the private companies that are licking their lips at the “massive opportunities” the new Accountable Care models open up for them to bid for out-of-hospital services (aka community health services) – a risk 999 Call for the NHS have been campaigning about all year.
The Report unwittingly bears this out when it notes (para 175) that
“More recently there has been an increase in non-NHS providers of NHS-funded care, with the most significant increase being in community health services. Community health service contracts have gone to a range of providers including charities, social enterprises and community interest companies as well as private companies.”
However the Report doesn’t connect the dots. Instead, Conclusion 16 says that:
“Rather than leading to increasing privatisation…we heard that using an ACO contract to form large integrated care organisations would be more likely to lead to less competition and a diminution of the internal market and private sector involvement.”
What they heard depended on who they listened to. They didn’t listen to campaigners, but instead chose to decry and misrepresent campaigners’ concerns about privatisation and Americanisation.
Privatisation must stay for the sake of patient choice and to “provide support when statutory services are stretched”
Para 37 comes out in favour of patient choice, and a mixed public/private NHS and social care system as a way to guarantee patient choice.
(There is plenty to be said about patient choice as an entirely inappropriate way of framing patients as consumers, but no time here to do it.)
The Report then comes up with the disingenuous formulation that “non-statutory” (eg private and third sector organisations) “must enhance and not undermine the ability of the NHS to serve local populations.”
The claim that private companies enhance the NHS, by helping it to eke out its meagre resources on acute and emergency hospitals rather than having to provide all NHS services, is one made by private companies themselves.
Use of the Accountable Care Organisation contract – which of course isn’t limited just to ACOs, but exists in variants for virtual and partally integrated Integrated Care Systems – might roll back the NHS internal market, as they claim – although it’s hard to see how, as Commissioners would still have to commission and oversee the Accountable Care services. But Recommendation 17, giving ACOs the freedom to involve and subcontract to private companies, is exactly how NHS privatisation would increase.
Equivocal Proposals for legislation
The primary legislation they recommend at some conveniently distant time – piously hoping it will be supported by a cross party consensus – doesn’t begin to address how to stop and reverse NHS privatisation, because they don’t think it’s a problem. In fact they recommend the NHS be a mixed public/private service, with “mostly” publicly -provided services. How Most is Mostly?
As a result, their proposed primary legislation is no substitute for the NHS Reinstatement Bill, that would remove the market and privatisation from the NHS and vice versa.
And then there’s the caveat (there’s always a caveat) that recommends removing ”barriers to integrated care” with secondary legislation – which means legislation without Parliamentary scrutiny or debate.
At first glance the recommendation of primary legislation for Accountable Care Organisations may seem like a significant if partial victory for Stop Accountable Care campaigners, since until now Sarah Wollaston’s position was that with a minority government and Brexit, no such legislation would be feasible. But, like most things in this report, it is so surrounded by equivocation that at second and third glance, it seems much less significant.
Pot calling kettle black
While the Report is very free with its criticisms of NHS campaigners’ misleading inaccurate messages and misrepresentations, it is not particularly honest itself. It’s worth looking at its tactics of disavowal and cherrypicking evidence..
Referring to Sustainability and Transformation Plans, they admit (Para 56) that:
“Public engagement was limited by instructions from national NHS bodies to ‘STP leaders to keep details of draft STPs out of the public domain’ ”.
They acknowledge in Para 60 that Sustainability and Transformation Plans leaked to the press included proposals to close services, reduce capacity and reconfigure hospitals.
But then the Report alleges that media coverage of these facts “politicised” “the STP brand” which then “became seen as a smokescreen for cuts to services”. In support of this allegation, they quote Chris Ham – apparently failing to register that even he, in the pay of NHS England, concedes that it was a “realistic concern that this was a cost cutting exercise rather than about the transformation of care.”
Somewhere along the way, the Report throws in a dismissive comment by Niall Dickinson, the Chief Executive of the NHS Confederation, that it was campaigners’ “palpable nonsense” that “tainted” the STP “brand”.
Conclusion and Recommendation 6 confirms their disavowal of the evidence they have assembled about the STPs’ shortcomings. It reduces the admitted facts of secrecy and cost cutting to “concerns” and “perceptions”:
“…Poor consultation, communication and financial constraints have fuelled concerns that STPs were secret plans and a vehicle for cuts. These negative perceptions tarnished the reputation of STPs and continue to impede progress on the ground…”
The report is very selective about what evidence makes it into their recommendations and conclusions.
The Report buys into NHS England’s proposed model of accountable care, using NHS England’s own language to describe it as
“ a move towards integrated, collaborative, place-based care”.
However, the report notes that the National Audit Office has found that there’s not enough evidence to show that Integrated care improves patient outcomes, cuts costs or hospital attendance and admissions.
But these findings do not make it into the Recommendations and Conclusions about integrated care. Instead, an entirely unconvincing assertion is made that
“More joined-up, coordinated and person-centred care can provide a better experience for patients…”
The Recommendations and Conclusions then glide to a consideration of whether by 2020 it’s possible to integrate health and social care across England, and for 50% of the country to be “covered by new care models”. The Report wants the Government to confirm if these targets are achievable and to provide detailed commitments about what integrated care patients will receive if they are.
This is a technocratic recommendation about how Accountable Care is implemented, rather than an honest examination of what it is and whether it’s desirable.
Campaigners’ concerns about NHS privatisation and Americanisation are “misleading assertions” that need to be dispelled
Rather than examine campaigners’ arguments and evidence, the Select Committee has dismissed us as “confus[ing] issues around integration” and expressing “misleading” “concerns…about the ‘Americanisation’ of the NHS.” (Conclusion 19).
The Report asserts that NHS campaign groups’ concerns about the Americanisation of the NHS are
“creating a climate that risks blocking the joining up of services in the interests of patients.”
Warming to their theme, Recommendation 22 urges that
“national bodies take pro-active steps to dispel misleading assertions about the privatisation and Americanisation of the NHS.”
We absolutely dispute the allegation of misleading assertions about privatisation and Americanisation of the NHS. Privatisation we have already discussed; as for Americanisation, the most cursory online search shows that the “new care models”, “modern workforce” and contracting and payment methods that Accountable Care is to impose on the NHS amount to a wholesale import into the NHS of US practices and methods.
Recommendation 21 repeats their reliance on un-evidenced assertions. It recommends that
“efforts to engage and communicate with the public on integrated care…should tackle head-on the concerns about privatisation, including a clear explanation to the public that integrated care will not result in them paying for services”.
But it provides zero evidence to rebut the insight of Doctors for the NHS, that integrating NHS services that are free at the point of need with social care services that are almost entirely privatised and means tested, risks conflating the two with the result that at the point where the boundary with social care services is unclear, patients may end up being charged for NHS services .
All they rely on as the basis for this assertion is an assurance from Simon Stevens.
This ignores so many issues it is ridiculous.