Tuesday 23rd October 2018

Save South Tyneside Hospital Campaign Response to National Survey on the Integrated Care Provider Contract

Kaiser Permanente is a U.S. HMO known for dumping patients in the street when their health insurance runs out. Approximating their model of 'care' is the goal of STPs→ACOs→ICPs
  • Question 1
    Should local commissioners and providers have the option of a contract that promotes the integration of the full range of health, and where appropriate, care services?
    No. Health services should be provided publicly by bodies in which people and health staff have control. Local commissioners - as part of the commissioner provider split - are part of the problem of fragmenting health services, so how can they be part of the solution? The same goes with NHS England and NHS improvement who are not public bodies but mechanisms to fragment services, so how can they integrate services? People and staff need to be in control of their health services - it requires a democratic solution and public responsibility.
  • Question 2

    The draft ICP Contract contains new content aimed at promoting integration, including:

    • Incorporation of proposed regulatory requirements applicable to primary medical services, included in a streamlined way within the draft ICP Contract.
    • Descriptions of important features of a whole population care model, as summarised in paragraph 30.
    Should these specific elements be amended and if so how exactly?
    Yes. It should be withdrawn. The CCGs will subcontract to the ICP and the ICP will subcontract to providers. None of this will be accountable in any significant way. It is bad for patients and bad for health staff. The contract arrangements are full of loopholes to enable ICPs to commission and be unaccountable. The contract is aimed at putting independent providers in control of our health services. These independent providers are not answerable to how they contract services and what they do. There will be even less ability of communities to have any say in how their health services are provided.
  • Question 2a
    Are there any additional requirements which should be included in the national content of the draft ICP Contract to promote integration of services?
    Your FAQ state on page 11. with a whole paragraph ending with Existing arrangements do not require providers to account for what they spend on contracted services. We disagree, any services that they subcontract (commission!) should be subject to parliamentary, local authority and community scrutiny before they are allowed to subcontract (commission!). The subcontracting is almost completely unaccountable.
  • Question 3

    The draft ICP Contract is designed to be used as a national framework, incorporating core requirements and processes. It is for local commissioners to determine matters such as:

    • The services within scope for the ICP.
    • The funding they choose to make available through the contract, within their overall budgets.
    • Local health and care priorities which they wish to incentivise, either through the locally determined elements of the financial incentive scheme or through additional reporting requirements set out in the contract.
    Have we struck the right balance in the draft ICP Contract between the national content setting out requirements for providers, and the content about providers' obligations to be determined by local commissioners?

    No. As previously stated on Page 11 of your FAQ: Existing arrangements do not require providers to account for what they spend on contracted services. So, any services that they subcontract (commission!).

    Also on page 10 of the same FAQ you say:

    NO. The ICP could not commission services. An ICP would be able to subcontract services within the scope of what has been commissioned to provide and the parameters of its contract with the CCG and with permission of the CCG. In principle this is not contrary to the statutory framework.

    We think this is a loophole to allow ICPs to carry out commissioning. As we said before, this should be subject to parliamentary, local authority and community scrutiny before they are allowed to subcontract (commission!), and ICPs are not accountable for what they spend to CCGs or NHS England. The subcontracting is almost completely unaccountable and will be open to abuse as commissioning of private companies by the back door.
  • Question 4
    Does the bringing together of different funding streams into a single budget provide a useful flexibility for providers?
    No. Because the service is fragmented into private and public corporate bodies that are increasingly being run on commercial lines and competing with each other, wasting huge amounts of resources on competition. No amount of integration or single budget streams will address the fundamental flaw, but it will be used by the ICPs and the government to cut back services, and their friends will profit from it. The government has responsibility to fund and provide as a public service to all the population, and give people equal access to the highest standards of health care. This system of single, or multi-stream is a red herring.
  • Question 5

    We have set out how the ICP Contract contains provisions to:

    • Guarantee service quality and continuity.
    • Safeguard existing patient rights to choice.
    • Ensure transparency.
    • Ensure good financial management by the ICP of its resources.
    Do you agree or disagree with our proposal that these specific safeguards should be included?
    Disagree. Contracts as we have stated will not safeguard services. This is frankly a lie.
  • Question 5a
    Do you have any specific suggestions for additional requirements, consistent with the current legal framework, and if so what are they?
    The government and any other body that represents such mechanisms that you are proposing has no right to implement such detrimental proposals and impose them on the population of England and Wales. There is no justice either in a government that circumvents the law to impose these U.S. style 'Accountable Care Organisations'. The government and any health bodies under it have the responsibility to fund and provide as a public service to all the population, and give people equal access to the highest standards of health care. The commissioner-provider split should be ended and all bodies should be public and subject to real democratic control as we have stated.
  • Question 6
    Should we create a means for GPs to integrate their services with ICPs, whilst continuing to operate under their existing primary care contracts?
    No. ICPs should not be in control of GPs or the health service for that matter.
  • Question 6b
    Are there any specific features of the proposed options for GP participation in ICPs that could be improved?
  • Question 7
    Do you think that the draft ICP Contract adequately provides for the inclusion of local authority services (public health services and social care) within a broader set of integrated health and care services?
    No. This will be a further burden on local authorities and their budgets. In fact the Integrated Care providers, by fragmenting and cutting the right to health care (through further creaming off the budgets between themselves government, and NHS England) will also impact on the further fragmentation and cutting of social care. Public health and social care services are not "contracts", they are actual services to be resourced. First come the services needed then the resource to provide it, not the other way around. Merging and tinkering with contracts is not a solution.
  • Question 8

    The draft ICP Contract includes safeguards designed to help contracting parties to ensure commissioners' statutory duties are not unlawfully delegated to an ICP:

    • It provides a framework within which decisions can be taken by the ICP, based on a defined scope of services which the commissioners require the ICP to deliver
    • It includes a number of specific protections, outlined in paragraph 83, which together prohibit the provider from carrying out any activity which may place commissioners in breach of their statutory duties
    Are there any other specific safeguards we should include to help the parties to ensure commissioners' statutory duties are not unlawfully delegated to an ICP?
    Yes. The whole idea of ICPs should be scrapped. As we have said, real democratic control of our health services should be implemented, otherwise all the abuses you guiltily mention will get worse.
  • Question 9

    The draft ICP Contract includes specific provisions, replicating those contained in the generic NHS Standard Contract, aimed at ensuring public accountability, including: Requirements for the involvement of the public as explained in Paragraph 89-93 Requirement to operate an appropriate complaints procedure Complying with the "duty of candour" obligation

    Should we include much the same obligations in the ICP Contract on these matters as under the generic NHS Standard Contract?
    How is it that you are talking about public involvement when you have conducted this consultation and survey behind closed doors and almost in secret. This shows what your public accountability measures are worth with standard or non-standard contracts. The consultation is a sham and no one will have any confidence in your specific protections or duty of candour on accountability. Nothing could enhance these contracts.
  • Question 10

    It is our intention to hold ICPs to a higher standard of transparency on value, quality and effectiveness, and to reduce inappropriate clinical variation. In order to achieve this the draft ICP Contract builds on existing NHS standards by incorporating additional provisions describing the core features of a whole population model of care and new requirements relating to financial control and transparency:

    Do you think that the draft ICP Contract allows ICPs to be held to a higher standard of value, quality and effectiveness and to reduce inappropriate clinical variation?
  • Question 11
    In addition to the areas covered above, do you have any other suggestions for specific changes to the draft ICP Contract, or for avoiding, reducing or compensating for any impacts that introducing this Contract may have?
    We have explained above.
  • Question 12
    Are there any specific equality and health inequalities impacts not covered by our assessment that arise from the national provisions within the draft ICP Contract?
    The proposals are policy objectives that have no basis in the real situation, which is that health inequality is worsening with the whole present direction. Looking at the Sustainability and Transformation Plans on which these ICPs are based, almost all of the downgrading of health services is having its highest impact on the most deprived areas. Policy objectives that are completely unreal about better community care and self care boil down to the most vulnerable people having to fend for themselves without the access to health services that they need in their localities. We thoroughly condemn this approach and direction for our health service.


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