*Breaking News 13th July 2021* It turns out there’s a reason that the NHS White Paper mentions “flexibly” or “flexibility” 38 times… The Health and Care Bill is about to have its second reading tomorrow, and will remove the statutory duty to provide hospital medical services – see Professor Allyson Pollock and Peter Roderick’s Health & Care Bill – Key Points.
Background to the Health and Care Bill: The NHS White Paper
The Government is racing ahead with legislation to fundamentally restructure and streamline healthcare and social care, saying that the lessons of COVID-19 must be learned even as the pandemic approaches its third wave, and while the NHS and social care are in disarray.
The NHS White Paper announced the Government’s reforms and it’s a tricky document – lulling the reader with bland platitudes (it talks a lot about “flexibility”) and rarely providing focused policy proposals. Let’s take a look at what the White Paper says (or refuses to say), and try to figure out where the Government is taking the NHS. The role of Optum/UnitedHealth in Integrated Care needs looking at too.
Please note that this analysis of the NHS White Paper provides important background, however the Health and Care Bill sets out the specific legal framework which is about to transform our rights to NHS care.
NHS Long Term Plan: Follow the money
The Long Term Plan deserves an essay in itself, but (briefly) it aims to cut UK healthcare expenditures, and one of the more important ways it does this is by “boosting out-of-hospital care”, in other words by shifting the NHS patient care burden from secondary care (hospitals) to primary care (general practice) and social care.
This strategy was suggested by the McKinsey report in March 2009 and has been pushed through by NHS England’s chief executive Sir Simon Stevens, but it raises significant concerns.
Firstly, the NHS is already one of the most efficient healthcare systems in the world, and therefore the fundamental idea of massively cutting healthcare expenditure needs to be challenged even at the best of times, and particularly after a pandemic when under-resourcing our public health services has resulted in paying out tens of billions of pounds to the private sector.
Secondly, in order to deal with the primary care burden envisaged by the Long Term Plan, the new GP contract transfers roles traditionally carried out by general practitioners to other professionals such as pharmacists and physiotherapists. This inverts the NHS healthcare model, increasing risk and inefficiency.
The entire premise of primary care is that a patient is seen first by a GP who is a generalist with broad knowledge of all branches of medicine. This is effective because it maximises the probability of catching serious diagnoses early, and because the first consultation requires significant acumen to tease out what is clinically important and what requires referral to hospital specialists.
The Royal College of GPs has highlighted the importance of the generalist healthcare model: “the first point of contact for any person seeking care for a new problem is nearly always with a ‘generalist’. Our respondents supported the role of medical generalists as being important in the ‘front line’ where problem mapping and diagnosis is essential”.
Pharmacists and physiotherapists are highly skilled healthcare professionals with very specific training – it’s unsafe to transfer a generalist role to them. The risk to patients of the new proposed model is proven by the fact that GPs refused to move to this model unless NHS England introduced State-backed indemnity for clinical negligence by GP practice staff.
The third major concern is that the logical end-point of the Long Term Plan is that the NHS budget will shift towards primary care, and GP practices are already particularly attractive for commercial exploitation. Cash injections to incentivise the transfer of general practice to cheaper non-generalist staff and State-backed indemnity for associated medical risk will massively incentivise corporate takeover. 'The Long Term Plan transfers primary care from GPs to non-generalist healthcare professionals. The risk to patients is proven by GPs' refusal to accept this model without State-backed indemnity covering clinical negligence by GP practice staff.' Click To Tweet
Integrated Care Systems – A back door to privatisation?
Here the NHS White Paper refers to problems of integration between the NHS (mostly free at the point of delivery, mostly provided by the public sector – but with rapidly increasing involvement of the private sector) and adult social care (mostly chargeable at the point of delivery, and almost completely provided by the private sector).
Simon Stevens hopes that legislation will “bring together the whole ability to plan and fund for a population”. However, privatisation of social care is far more advanced than privatisation of healthcare. For instance, 95% of domiciliary care was directly provided by local authorities as late as 1993, but this was only 11% by 2012.
The question is whether “removing the barriers” between the NHS and social care to create Integrated Care Systems will involve the public sector taking over social care, or the private sector taking over the NHS. The White Paper avoids providing a clear answer to this question.
Bearing in mind the NHS’s history of a costly and ineffective internal market (see below), it seems sensible to ensure that we’ve seen evidence of benefit before rushing ahead and overhauling the NHS’s infrastructure. In this respect, data suggests that the integrated care model has failed to show the benefits proclaimed above by the NHS White Paper.
For instance, Parry et al’s carefully controlled study showed integrated care was not associated with a reduction in healthcare utilisation but rather an integrated care model increased elective inpatient admissions and general practitioner workload in Tower Hamlets.
A systematic review of UK and international evidence for the effects of integrated care concludes as follows: “The system-wide impact on community and hospital-based services was unclear, with reports of both increased and decreased use of community services, although we identified no evidence to suggest that models of integrated care increase use of secondary care. Neither was there clear evidence regarding whether models of integrated care are cost neutral, increase or reduce costs.” 'Systematic review of the effects of integrated care has shown no clear benefits. Why are we rushing ahead with massive re-organization of NHS and social care, with little evidence of benefit, in the midst of a national emergency?' Click To Tweet
Abolition of NHS procurement rules – Unexpected outcomes?
The White Paper argues that the procurement regime – forcing clinical commissioning groups to put NHS contracts over a certain value out to tender – creates “transactional bureaucracy” which wastes time and resources. It therefore proposes removing NHS services from the scope of the Public Contract Regulations 2015 and section 75 of the Health and Social Care Act 2012.
It’s widely acknowledged that competition in the NHS hasn’t improved efficiency and some have welcomed the abolition of compulsory tendering because they think it will reduce privatisation. However, deregulating NHS contracts won’t prevent privatisation. In the absence of the NHS being specified as a preferred provider of services, deregulation allows the Government to simply hand out NHS contracts to private companies without oversight.
Bearing in mind significant questions over lucrative contracts handed out to the private sector during COVID-19, this opens the door to massively increased and inefficient transfer of NHS services to the private sector without oversight and funded by the tax-payer. 'In the absence of the NHS being a preferred provider of services, the removal of section 75 allows Government ministers to hand out contracts to private healthcare companies without oversight. We've seen the likely outcome during COVID-19.' Click To Tweet
NHS internal market – Misrepresented by the White Paper
This is a misrepresentation of the value provided by the internal market and the purchaser/provider split. For instance read the House of Commons Select Committee on the impact of the NHS purchaser/provider split: “Whatever the benefits of the purchaser/provider split, it has led to an increase in transaction costs, notably management and administration costs. Research commissioned by the DH but not published by it estimated these to be as high as 14% of total NHS costs. We are dismayed that the Department has not provided us with clear and consistent data on transaction costs; the suspicion must remain that the DH does not want the full story to be revealed.”
Even the Spectator – broadly supportive of the current Government – has accepted that the internal market and the purchaser-provider split have resulted in inefficiency. The difficulties in applying the economic market specifically to healthcare are well-known and were most convincingly stated by the American Nobel prize-winning economist Kenneth Arrow.
Jane Lewis, Emeritus Professor at the London School of Economics, writes, “Taking the long view, the establishment of a purchaser/ provider split and in particular the new contractual arrangements demanded by it were highly significant and were linked to substantial rises in management and transaction costs after 1991 (Turner and Powell , 2016; HoC Select Committee on Health, 2010)”. 'The White Paper misrepresents facts. The NHS internal market failed – at great expense to taxpayers. Similarly, Integrated Care Systems benefit the companies which manage them, but there's scant evidence they will benefit patients.' Click To Tweet
What’s the role of Optum/UnitedHealth in Integrated Care Systems?
Remarkably, the White Paper mentions the voluntary sector, charities, partners, and “NHS and local government forming dynamics partnerships”, but it never specifically refers to the private sector. This is despite Optum (the data analytics face of the American insurance company which previously employed Simon Stevens) acting as NHS England’s National Development Partner to promote the integrated care which is one of the cornerstones of the White Paper.
It’s worth remembering that the White Paper requires private providers of social care to provide access to their data, and it’s clear that the American insurance company United Healthcare/Optum is in pole position to exploit that data. This data can be used to identify “high-cost” patients in insurance models and has enormous commercial value.
Of course data sharing is required for integration, but if the private sector is playing a significant role in integrated care, then that should be spelled out in the White Paper so that the British public and key stakeholders can properly evaluate the likely impact of Government proposals. After all, that’s the purpose of a White Paper! 'If the private sector is playing a significant role in integrated care, that should be spelled out in the White Paper so the British public and key stakeholders can feed back on Government proposals. That's the purpose of a White Paper!' Click To Tweet
COVID-19: Learning the wrong lessons
COVID-19 has indeed changed the landscape of UK healthcare, but the White Paper cannot succeed in positively transforming the NHS if it begins from a false position.
Rather than look ahead with confidence and build on our “audacious legacy”, we should acknowledge that we have suffered significant COVID-19 mortality, partly attributable to policy decisions made regarding intensive care provision, public health infrastructure, NHS bed capacity, and spending on social care. NHS Trusts are now farming off surgical waiting lists wholesale to the private sector, at the expense of the taxpayer.
The Government appears to be rushing through the most significant re-organization of NHS services since many decades, without making any effort to learn lessons from the greatest challenge faced by the NHS since its inception. Legislation is pressing ahead before the parameters of a COVID-19 inquiry have even been decided.
This smacks of political expediency, exploiting the political disarray caused by COVID-19, rather than a considered strategy in the best interests of the public’s health. The White Paper’s declaration that“We must seize it” poses the question: Who is seizing what?
It’s undeniable that nurses, doctors and other frontline workers have performed heroically during the COVID-19 pandemic, but NHS England’s management of this pandemic has resulted in significant avoidable mortality, and decisions by senior NHS executives have arguably contributed to the deaths of thousands of patients in social care.
It’s important to understand the causes of inadequate NHS capacity during COVID-19, and how healthcare strategy over the last 30 years led to such disastrous outcomes. We have one of the lowest bed-to-patient ratios in the OECD. Due to this capacity problem, we have had to rely increasingly on the private sector to deal with NHS waiting lists even before COVID-19.
During the pandemic, Simon Stevens brokered an NHS deal with the private sector which kept private hospitals open at taxpayers’ expense – while not using most of their beds. The exact contractual arrangement, and the cost of keeping the entire private sector afloat during COVID-19, have not been disclosed.
Regarding new hospitals being built in just a matter of days, the Nightingale Hospitals have rightly been referred to as white elephants. These “hospitals” were hugely expensive rented warehouses with beds but inadequate resources or staff which were never able to deliver significant levels of care.
Digital and data exploitation – Who benefits?
Digital technology and data are welcomed by NHS professionals. However, it is the financial exploitation of data which needs to be considered carefully. Is data being used to improve healthcare for patients, or to improve profitability for private providers or insurance companies?
In the Information Age, the value of NHS data may well be greater than the value of NHS land. The vulnerability of the public purse to corporate exploitation of our data will be far in excess what we’ve experienced through the Public Finance Initiative.
It’s important to realise that currently NHS England’s National Development Partner for using data and analytics to promote Integrated Care Systems is Optum UK – a front company for United Healthcare, the US’s largest private healthcare insurance company and the former employer of Simon Stevens.
If Optum or other private corporations control our healthcare data (or even if they control the interpretation of it), then large regional integrated care systems managing the health and social care of millions of people will be unable to function without those private corporations.
Given serious questions about contracts given to Google DeepMind, Amazon and Babylon Health, the mismanagement of data during the Test & Trace scheme, and recent public dismay about proposals to share primary care data without the explicit consent of patients, it’s important that we ensure our data is exploited for our benefit. 'If Optum or other corporations control our healthcare data, then large integrated care systems managing the health and social care of millions of people will be vulnerable to corporate exploitation. Have we performed a risk assessment?' Click To Tweet
Discharge to Assess – Is this the NHS “putting patients first” ?
This proposal raises serious clinical concerns. Currently, there is a legal requirement for hospitals to assess a patient’s safety to go home before discharging that patient, ie “Assess to Discharge”. For instance, if an elderly or infirm patient has tripped over at home and broken their hip, then physiotherapists and occupational therapists must assess their safety before allowing them home.
The Government plans to reverse this sensible and established legal requirement. “Discharge to Assess” suggests that NHS England will discharge patients home to assess if they’re safe to be at home! This policy reversal is unsafe and will lead to increased morbidity as well as increased bureaucracy and inefficiency if the patient requires emergency social care or rapid re-admission to hospital.
The Better Care Fund amounted to £5.650 billion for 2018/19, with an additional £1.5 billion of additional social care grant funding for the same year. Local authorities have to submit a joint spending plan for approval by NHS England as a condition of the NHS contribution to the Fund being released into pooled budgets. If you follow the money, you’ll find the Better Care Fund is an NHS subsidy for social care run by private companies.
During the first wave of COVID-19, the NHS funded local authorities to accept hospital patients within 3 hours of being designated as “clinically safe” (eg not on intravenous medications) – this arguably contributed to many deaths in the care sector. Rather than learn lessons, the Better Care Fund now provides financial incentives for cash-strapped local authorities to accept the risks of “Discharge to Assess”.
For NHS clinicians, it’s a highly disturbing policy. For NHS England’s chief executive, who honed his skills in the United States healthcare market where patient dumping is the norm, it’s just business as usual. 'For NHS clinicians, 'Discharge to Assess' is a disturbing policy which can put patients at risk. For NHS England's chief executive, who honed his skills in the US healthcare market where patient dumping is the norm, it's just business as usual.' Click To Tweet