Integrated Care Regulations
(5 years, 9 months ago)
Commons ChamberRead Hansard Text Read Debate Ministerial Extracts
Jonathan Ashworth (Leicester South) (Lab/Co-op)
I beg to move,
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, be annulled.
I am grateful that we have found time to debate this prayer motion in my name and the name of my right hon. Friend the Leader of the Opposition. For the Government to have attempted to make these changes without proper scrutiny is a huge discourtesy to the House. These changes are fundamental, with potentially far-reaching implications for the NHS, and they have aroused concern—[Interruption.]
Madam Deputy Speaker (Dame Eleanor Laing)
Order. It is not fair to the hon. Gentleman that people who have voted are now having conversations here. I would be grateful if people who wanted to talk about other things left the Chamber.
Jonathan Ashworth
The changes in the regulations have aroused considerable concern in the country, and proper parliamentary time should have been made available for a proper debate on them; they should not have been made through secondary legislation.
The Opposition oppose the regulations and will seek to test the House’s opinion on them. We oppose the changes not because we are against integration. We have long called for greater integration of services to offer seamless care to patients, because the demands on the NHS are of a different nature from those of 71 years ago, when a Labour Government created the NHS with a tripartite structure. In those days, life expectancy was so much shorter, and infectious disease was the overwhelming medical challenge. In 2019, we are worlds away from the days when 30,000 hospital beds were set aside for the treatment of tuberculosis, or when wards were filled with row after row of iron lungs to treat those suffering from polio. Today, we are all living longer, with a variety of complex conditions, from diabetes to cardiovascular disease and chronic obstructive pulmonary disease—conditions that increase the risk of a poorer quality of life and mean a greater risk of premature death. Indeed, around 14.2 million people in England—nearly a quarter of all adults—have two or more conditions. More than half of hospital admissions and out-patient visits, and three quarters of primary care prescriptions, are for people living with two or more conditions.
The issue is not just ageing and frailty; poverty takes its toll. People in the most deprived areas of England can expect to have two or more health conditions at 61 years—10 years earlier than people in the least deprived areas. Health inequalities are widening, while advances in life expectancy are stalling. An ageing population, the increase in long-term conditions, and the increasing number of people with multiple health conditions means that we need to integrate services. Sometimes in these debates, when we talk of long-term conditions, we suggest that we are talking about a homo- geneous group, but it is quite the opposite. We could be talking of a 61-year-old man with renal failure and high blood pressure, or a 101-year-old woman with profound deafness and blindness. The way that such conditions affect quality of life, and the extent to which they are amenable to medical intervention, is likely to vary.
If health services are not better co-ordinated and not integrated, there is a greater risk to patient care through the poor co-ordination of medical care and increased time spent managing illness. The need to manage multiple medications may lead to poorer medication adherence, adverse drug events, and the aggravation of one condition by the symptoms or treatment of another. It can also mean damaging self-management regimes in which there are competing priorities, and a bewildering landscape for patients, who are often of an advanced age, with cognitive impairment and limited health literacy, so we support integration.
I have seen integration working on the ground. Just last week, I was in Bolton, where I visited the Winifred Kettle centre to see the model of integrated multi-agency work bring together mental health professionals, pharmacy, physio, occupational therapy and social workers. In Bury, I heard about how the local council’s chief executive doubles up as the chief executive of the clinical commissioning group. In Luton and Dunstable I saw with my own eyes that the hospital trust has various social care workers in its discharge unit, helping to avoid the indignity of huge numbers of elderly patients being trapped in hospital, ready for discharge but delayed for days on end, as happens too often. In Wolverhampton, a fascinating example is being developed: the hospital trust is taking on and employing GPs directly. In Wolverhampton, they call it vertical integration, although some might wish to go as far as to suggest that it is the nationalisation of general practice, something that not even Nye Bevan was able to achieve.
A Labour Government would move away from a competitive landscape of autonomous providers to one of area-based care delivered through integration, collaboration, partnership and planning. We will restore a universal, publicly provided and administered national health service. Locally, we envisage something akin to health and care boards, with a duty to provide health not only for those on a CCG list but for all residents. Nationally, the Secretary of State’s duty to provide care will be reinstated. We are consulting on these matters with patients, staff and wider stakeholders.
Mr Jim Cunningham (Coventry South) (Lab)
Very quickly, does my hon. Friend not agree that the big problem with integration, if we support it, is the lack of funding, and the lack of proper training in the various disciplines? Only a couple of years ago, there was a cut in the funding for pharmaceuticals.
Jonathan Ashworth
My hon. Friend makes a very important point. Integration is not about saving money. For integration to work properly, it needs to be fully funded, and, of course, the NHS has been through the biggest financial squeeze in its history. We do not oppose integration. Indeed, that is why the previous Labour Government introduced a section 75 partnership arrangement, and why we were so vociferous in our opposition to the Andrew Lansley Health and Social Care Act 2012, which went completely counter to international evidence and exacerbated local fragmentation of health structures. It is a delicious irony that Ministers, all of whom were dragooned through the Lobby to support the Lansley Act, despite expert after expert warning them what a mistake it would be to press ahead with it, are now trying to propose regulatory changes, so that we can essentially work around that Act. The reason why we cannot support the regulations today is that the most damaging part of that Act is still on the statute book.
Tracy Brabin (Batley and Spen) (Lab/Co-op)
On the point about the Health and Social Care Act, a third of the contracts have been awarded to private providers, and millions were wasted when they collapsed. The explanatory memo for this 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 that is not legally binding. To protect our NHS, do we not need to know definitively that providers will be public, not private?
Jonathan Ashworth
My hon. Friend is absolutely right. Of course, the Minister cannot give that reassurance because of the Lansley Act that Ministers voted for in 2011.
Justin Madders (Ellesmere Port and Neston) (Lab)
I am only sorry that I cannot be with my hon. Friend on the Front Bench tonight. I have really enjoyed working with him; he is a fine shadow Secretary of State, and I know that he will make an excellent Secretary of State. Unfortunately, I cannot be with him, because when we on these Benches vote against the Whip, we have to deal with the consequences.
As my hon. Friend knows from many debates I have taken part in for the Opposition, despite repeated questions to various Ministers, there has been no absolutely no reassurance that the private sector will not continue to be involved in these matters.
Jonathan Ashworth
My hon. Friend makes his point typically eloquently and with force. May I say to him that we miss him on the Labour Front Bench? He was a real rock in the shadow Health and Social Care team. It is typical of him that when he decided last week that he could not support the Labour Front Bench position on a referendum, he took the honourable course of action and chose to leave the Front-Bench team. I think that he has the respect of many in the House for that position.
This is the nub of our opposition tonight. Contracts are still being put out to competitive tender, even when some commissioners claim that they do not wish to do this. Here lies the danger: nothing prevents, and some things might encourage, these integrated care partnership contracts being put out to tender and perhaps being won by a private sector provider. Ministers repeatedly tell us that ICPs, and before them accountable care organisations, are not about ushering in a further role for the private sector. If that is the case, and if patients and staff are to have confidence that the ICP contracts will not end up in private hands, the Government’s overarching competition legislation must be changed first. As that legislation has not been changed, and as we will still have commercial contracting for the delivery of medical services, there is a risk that a multi-billion pound contract covering hundreds of thousands of people and packaged up for 10 to 15 years could be handed over to a big provider. That is why the Health Committee, which is broadly supportive of these integrated care models, issued this warning in its report:
“The ACO model”—
it was using the terminology of the time—
“will entail a single organisation holding a 10–15 year contract for the health and care of a large population. Given the risks that would follow any collapse of a private organisation holding such a contract and the public’s preference for the principle of a public ownership model of the NHS, we recommend that ACOs, if introduced, should be NHS bodies and established in primary legislation.”
We agree.
The impetus for this contract comes from the example of Dudley, which I am sure the Minister will want to talk about. When the chief executive of Dudley CCG attended the Select Committee, even he conceded—although he said that it was unlikely—that because of the procurement rules, it would not have been possible to have kept out private providers applying for the contract. When asked whether the contract could go to a private provider, he said:
“In theory, it is technically possible for that to happen”.
Although Mr Nigel Edwards of the Nuffield Trust shared the Minister’s scepticism that the contract could go to a private provider, he did concede before the Select Committee that:
“To privatise in the sense of handing over all the assets and staff to a private contractor is a theoretical possibility.”
NHS England’s own analysis of the contract published at the end of last week concedes:
“However, it should be understood that current NHS law and EU and domestic procurement law prohibits CCGs or NHS England from taking steps, whether through evaluation criteria used in a procurement or otherwise, to disqualify certain categories of provider (e.g. independent sector providers) from bidding or being awarded commissioning contracts.”
This is our first objection, because Labour is not prepared to nod something through when there is a theoretical possibility hanging over us that, in the words of NHS England, an independent sector provider could not be disqualified from being awarded commissioning contracts.
Liz Twist (Blaydon) (Lab)
Does my hon. Friend agree that to cure these problems, we need not secondary legislation, but a thoroughgoing review of NHS legislation?
Jonathan Ashworth
My hon. Friend is right; we need to sweep away the Lansley legislation and put the NHS on a sustainable public footing. NHS England attempts to reassure those who are concerned about this contract by putting in place some further conditions. It talks about transparency and insisting on a “minimum level of assets”. Note the qualifier “minimum”—not all assets. It also talks of a
“restriction on carrying out any business other than that required by the ICP Contract”.
Again, note the words used—not a prohibition on other business activities, just a restriction. This is in the circumstance when the contract is awarded to a non-statutory provider.
NHS commissioners are obliged by law to advertise many larger NHS contracts, giving firms such as Virgin Care the chance to bid. Since the Lansley Act came in, £10 billion of contracts have gone to private providers, and there is a further £128 million of NHS tenders in the pipeline. It is all very well for the Secretary of State to go to the Health and Social Care Committee as he did a few weeks ago and say:
“There is no privatisation of the NHS on my watch, and the integrated care contracts will go to public sector bodies to deliver the NHS in public hands.”
The Secretary of State is not in a position to make that promise to the Committee, because of the legislation that is in place.
Dr Sarah Wollaston (Totnes) (Ind)
As my Committee has already been quoted, I think that it might assist the House if I were also to quote from the conclusions that we came to on this issue. The Committee said:
“We recognise the concern expressed by those who worry that ACOs could be taken over by private companies managing a very large budget, but we heard a clear message that this is unlikely to happen in practice. Rather than leading to increasing privatisation and charges for healthcare, 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.”
Jonathan Ashworth
The hon. Lady makes an interesting point. She is correct in as much as there is not currently a long queue of companies lining up to take control of whole health systems, but that could change if some new form of Transatlantic Trade and Investment Partnership is brought in by a post-Brexit deal. A number of these companies are becoming increasingly litigious in the courts, which is why Virgin Care took the NHS in Surrey to court. However, even if a private provider is not gifted a whole contract, which is the point that the hon. Lady is making, there is nothing to prevent it from buddying up with NHS bodies in joint ventures as a way of exercising influence over the way in which local health systems are configured. There is already evidence of private sector involvement in the establishment of the integrated care system, with Centene UK—an offshoot of an American health insurer—working with Capita in the Nottingham ICS.
Karin Smyth (Bristol South) (Lab)
Earlier in his remarks, my hon. Friend talked about confidence for people locally in what is happening in the NHS. Further to the point made by the hon. Member for Totnes (Dr Wollaston), only in February NHS England itself issued its case for primary legislative changes in which it says, with regard to these proposals, that it wants to
“start a broad process of engagement with the NHS, its partner organisations and those with an interest in how our health service operates.”
That will hopefully involve patients and the public. In Bristol, we embarked on a 10-year contract for community services on the day after the NHS plan was invoked without consultation with local people, an assessment of basic health needs or alignment with the rest of the situation. The problem is that we have yet another change that people locally do not have confidence in. It really is time for the Government to come forward with a cohesive change for the future.
Jonathan Ashworth
That is absolutely right. Notwithstanding the sincere views of the Select Committee, there is a lack of confidence out in the country about the way in which these commercial contracting arrangements work. We are seeing that in Bristol, as my hon. Friend so eloquently outlined. Despite the blasé attitude of the Secretary of State in the Select Committee, this is the same Secretary of State who has sat back and done nothing while a PET-CT cancer scanning contract in Oxford is privatised, leading to a fragmented service putting patient safety at risk.
Anneliese Dodds (Oxford East) (Lab/Co-op)
I know my hon. Friend has been working very hard on this issue. I have had droves of patients and staff contacting me with their concern about what is happening. They are astonished that this privatisation is continuing given the comments made by the Secretary of State. There seems to be no willingness at all for any challenge to NHS England’s decision, which is going above the heads of those who deliver the care and which, as my hon. Friend says, would threaten its quality and safety.
Jonathan Ashworth
We keep being told by Ministers, by those who are favour of integrated care and by various interested stakeholders that Labour Members are scaremongering and that we have nothing to worry about—that it is all going to be fine and all going to be in the public sector—yet at the same time we are seeing controversial privatisation after privatisation all across the country, of which the one in Oxford is just the latest example. This has happened since the Secretary of State went to the Select Committee and said that there would be no privatisation on his watch.
In south-east London, private companies are in a three-way fight for the biggest-ever NHS pathology contract—a £2.2 billion contract for 10 years. If the Secretary of State was sincere in his commitment to no privatisation on his watch, he would bring forward legislation to ensure that ICPs are statutory public bodies that are publicly accountable. He would first take the advice of the NHS itself, as embodied in the long-term plan and the subsequent proposals for legislative change, and rid our NHS of the morass of competition law and economic regulation that was brought in by the Health and Social Care Act 2012. Everyone agrees that this particular aberration has had its time.
While the NHS proposals do not yet go as far as Labour Members would want and would not resolve all the problems of the internal market and private sector involvement that our NHS struggles with, they would remove the default assumption for competitive tendering that would currently make many ICSs feel obliged to put contracts for ICPs out to tender for fear of falling foul of the competition rules. Overall, they provide a far preferable base from which to pursue integrated care than the maze of contradictions and obstacles that Andrew Lansley’s Act forced on them. Rather than this regulated change, why is the Minister not bringing forward the legislation that NHS England has called for?
I have two other quick points for the Minister. The new secondary legislation seeks to substantially change the regulations underpinning the existing contractual arrangements for the provision of NHS GP services. We should remember that general practice is already hard to recruit for and we are already losing GP numbers, yet the proposal to incorporate GP practices into ICPs appears to cut across the idea of GPs beginning to work in wider networks covering 30,000 to 50,000 patients, retaining their GP contracts but sharing common resources. That was highlighted as a direction of travel to be celebrated by the Prime Minister when launching the long-term plan.
GP practices can already network and collaborate without this new contract. The contract will offer a sweetener to GPs of new money if a GP practice signs up to the new contract, but the proposals have been opposed by the BMA. Dr Richard Vautrey has said:
“We have repeatedly expressed our serious concerns about ICP contracts which leads to practices giving up part or all of their General Medical Services contract as a result. Practices should not feel pressured into entering an ICP contract as to do so could leave their patients worse off.”
Perhaps the Minister can explain why he is correct and Dr Vautrey is wrong.
I want to make a quick point about the pooling of budgets with respect to universal free-at-the-point-of-use NHS and means-tested social care. If the boundaries between health and social care are dissolved, will the Minister mandate ICPs and clearly specify that which is considered healthcare and that which is considered social care? I raise that because we are already seeing CCGs across the country cutting back on their responsibilities to provide continuing healthcare for some of the most vulnerable people. Can he guarantee that some services currently provided free on the NHS—whether rehabilitation care or nursing care provided by district nurses, such as wound care or continence care—will not suddenly be designated as social care, so that charging creeps into the system?
Kevin Hollinrake (Thirsk and Malton) (Con)
The hon. Gentleman talked about the funding of social care. One of the recommendations made by the Health and Social Care Committee, in concert with the Housing, Communities and Local Government Committee, as a solution to adult social care funding, was a system of social insurance. Would he support that on a cross-party basis?
Jonathan Ashworth
The hon. Gentleman is a passionate campaigner for his social insurance proposal, and I have heard him make that point many times. I say to him gently that when the Government bring forward their Green Paper—I emphasise the word “when”—we will engage fully in the debate, and I am sure he will make that point then, whether the debate happens this year, next year or the year after; we will wait and see.
There is a problem with the dissolving of boundaries between health and social care and what that could mean, with charges creeping into the system for some services that were previously considered NHS services but are now designated as social care services. Is the Minister prepared to mandate ICPs, so that we have clear guidelines about that? Finally, where is the patient voice in any of this? Where are the guarantees that decisions will be made not only in public but with the public involved in the decisions that affect them locally?
We on the Opposition Benches support integration; we have long called for it. We support greater collaboration. We support the planning of health and social care delivery in local areas. We support restoring local area-based health bodies delivering care, rather than the fragmented mess we have today. We have, of course, had such bodies before—we used to have district health authorities and strategic health authorities, and some have suggested rather mischievously that we seem to be going back to what we used to have in the past.
Until the default assumptions of tendering and wasteful procurement exercises are removed from primary legislation, such secondary legislation will always create further dangers of private operators gaining control of NHS services. Until that is done, Ministers will have no one to blame but themselves if the spectre of privatisation continues to haunt their ICP plans. We oppose NHS privatisation. We oppose NHS cuts. We oppose anything that undermines the fabric of a public national health service. We oppose these regulations. We seek to annul them, and I commend our motion to the House.
The Minister for Health (Stephen Hammond)
Although we oppose the motion, I welcome the opportunity to debate the regulations. The NHS long-term plan, which was published in January, set out a clear blueprint for fully integrated community health in the NHS for the first time in its history. The plan highlighted the intention to dissolve the historical distinction between primary and community health services and to break down the traditional barriers between care institutions, teams and funding streams, so as to support the increasing number of people with long-term health conditions, rather than viewing each encounter with the health service as a single unconnected episode of care.
NHS organisations will increasingly focus on population health by delivering the so-called triple integration of primary and specialist care, physical and mental health services, and health with social care, which is consistent with what doctors have consistently reported they need. I obviously welcome the commitment from the shadow Secretary of State, the hon. Member for Leicester South (Jonathan Ashworth), to integration. Today, the integration of services can take place through collaboration and co-operation, including some local alliance arrangements. However, in some areas, people working on the ground have told us that it would be better to have a lead provider to take responsibility for the integration of services for a population through an integrated care provider contract.
It is worth making the distinction between integrated care providers, which we are discussing tonight, and integrated care systems. An integrated care system growing out of the current network of sustainability and transformation partnerships will provide a platform on which commissioners can make shared decisions with providers about how to use resources, design services and improve population health. The long-term plan has set out an ambition for all STPs to evolve into ICSs. Integrated care providers, or ICPs, will be a new way of integrating health and care services so that people’s care is co-ordinated around them.
NHS England has developed the ICP contract to enable local areas to commission local health and care services, including primary medical services through a single contract. The intention is to establish the right organisational and financial incentives for providers to collaborate in order to deliver preventive, proactive and co-ordinated care. It is important to underline that ICPs are not new types of legal entity, but provider organisations that have been awarded ICP contracts. In the long-term plan, NHS England underlined that, when the contract is made available for use, it expects ICP contracts to be held by public statutory providers, and I want to discuss that a bit more in my remarks later.
Turning to the particular statutory instrument we are discussing tonight, we have identified a number of regulations that need to be amended to allow the first ICP contract to be awarded.
Thelma Walker (Colne Valley) (Lab)
In the last year, I have been on numerous Delegated Legislation Committees, and I have been shocked by the complex and far-reaching changes the Government have forced through without appropriate scrutiny. Can the Minister justify why substantive change to existing regulations should not be part of a Bill and subject to parliamentary scrutiny?
Stephen Hammond
As the hon. Lady knows, this has been subject to considerable scrutiny. It has been scrutinised by the Health and Social Care Committee, as she has already heard from its Chairman. She will also have heard that it has been subject to a number of other scrutiny processes, including judicial reviews.
Dr Paul Williams (Stockton South) (Lab)
The Minister is correct in saying that there has been some analysis of integrated care partnerships by the Health and Social Care Committee, but it has not scrutinised this statutory instrument. The Select Committee actually recommended very clearly that ACOs or ICPs should be NHS organisations. Will the Minister say why he should not accept the Committee’s recommendation?
Stephen Hammond
As the hon. Gentleman knows, the long-term plan has set out that the ICP contracts will be held by public statutory providers. That point has been made and reiterated several times not only in the Select Committee’s scrutiny, but in the remarks that the Committee and a number of people have made about privatisation. The Chairman of the Health and Social Care Committee has already intervened on the shadow Secretary of State, but she has said:
“The evidence to our inquiry was that ACOs, and other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”
Dr Wollaston
Will the Minister assure the House that only public statutory providers will hold these contracts? That would be reassuring, as the language on this is not completely clear. Will he also give some assurance regarding the Select Committee’s other proposal, which is that the policy should be carefully piloted and evaluated? If it is done first in Dudley, followed by careful evaluation, I would be prepared to support it. If he cannot give reassurance on those points, it would be difficult for me to support the regulations.
Stephen Hammond
I can give the Chair of the Select Committee the assurance that the ICP contract will be made available in a controlled and incremental way, conditional on the successful completion of NHS England and NHS Improvement assurance through the integrated support and assurance process. That incremental process is, I think, in line with what she and her Committee recommended.
Jonathan Ashworth
Will the Minister confirm that, because of the competition and procurement rules and the regime brought in by the Andrew Lansley Act, he cannot rule out the possibility of an independent provider winning a contract? He might say it is unlikely, but he cannot rule out the possibility, so why does he not introduce a measure—a simple one-clause Bill, perhaps—to give the assurances that many campaigners want?
Stephen Hammond
The hon. Gentleman is right: it is highly unlikely. More than that, it is stated and restated in the long-term plan that NHS England has the clear expectation that the ICP contracts will be held by public statutory providers. He knows that, and others who have discussed this point have made it clear.
Justin Madders
I have a simple question and we would like a simple answer. Yes or no: do the Government intend to repeal section 75 of the Health and Social Care Act 2012?
Stephen Hammond
As the hon. Gentleman knows, the NHS has proposed in a recent legislative document that it looks at a number of issues. It is important that that round of engagements takes place, and the Government will consider what is said.
The majority of the amendments we propose simply ensure that the regulatory framework that applies to contractual arrangements for the provision of healthcare services continues to apply where services are provided under the new ICP contract and to those organisations that hold a contract. That is an important safeguard that, in simple terms, helps to ensure that care provided under an ICP contract is subject to all the same rules as care provided under existing and other NHS contracts, such as those governing the handling of complaints and the reimbursement of travel expenses.
The shadow Secretary of State has asked me to comment on the substantive change being proposed, underpinning the existing contractual arrangements for the provision of NHS GP services. The regulations will allow GPs who are currently providing services under existing contractual general medical services or personal medical services arrangements to suspend, rather than terminate, those arrangements in order to provide services under an ICP in what is known as a fully integrated arrangement. The British Medical Association has underlined that GPs should not be pressured into joining an ICP arrangement, and we want to make it clear to the House tonight that the participation of any individual GP practice is entirely voluntary. Any role in any ICP will be for them to decide. Allowing the suspension of GP contracts allows GPs to take part in an ICP arrangement but keeps the option available to them of returning to their previous contract.
The hon. Gentleman expressed a number of concerns about the ICPs. He implied that they had been brought in by stealth. In fact, the proposals have been subject to significant scrutiny by Parliament and the public, particularly in the past year. We have already discussed the examination of the evidence by the Health and Social Care Committee, which published a report last summer, which is, I believe, largely supportive of ICPs, recognises potential benefits and sets out helpful recommendations on introducing them in England. I have described the consultation processes previous iterations of the ICP contract and the regulations have gone through.
Moreover, as the Health and Social Care Committee was promised, NHS England has completed a full public consultation on the ICP contract and announced through the long-term plan that the ICP contract will be available for use. NHS England’s full response to the consultation was published on 15 March.
Various people have made points tonight about the privatisation of the NHS and said that ICPs are a route to privatising the NHS. They are clearly not.
Stephen Hammond
The NHS has stated clearly that NHS England’s expectation is that these contracts will be held by public statutory providers. The hon. Lady, who is making a number of points—[Interruption.] She says she is not making them, but shouting at me. Indeed, she is shouting at me.
Stephen Hammond
Oh, she is chuntering at me. While she is chuntering at me, she might like to consider what the King’s Fund has said about the claims of mass privatisation, which is that they are “hugely overstated”. I have already quoted the Chair of the Select Committee, who said that the evidence to its inquiry was that ICPs and
“other efforts to integrate health systems and social care, will not extend the scope of NHS privatisation and may effectively do the opposite.”
It is important to recognise that NHS England has taken measures to build a clearer narrative around integrated care. The long-term plan, which will be backed by £20.5 billion extra by 2023-24, will introduce integrated care for patients in England over the next decade.[Official Report, 19 March 2019, Vol. 656, c. 6MC.] Where local commissioners propose to use ICP contracts, they will have to ensure that it is an effective and beneficial option for the local area. The regulations will ensure that the healthcare of this country is improved by integrated care providers. I commend them to the House.
Dr Philippa Whitford (Central Ayrshire) (SNP)
As I have said in many debates, I totally support integration. That is the journey we have been on in Scotland for almost 20 years. We amalgamated some trusts after devolution, we got rid of hospital trusts in 2004 and we got rid of primary care trusts in 2009. We had the health side run by health boards, which are statutory bodies that carry out area health and social care planning for a population. The integration between health, which is free, and social care, which is means-tested, was passed in legislation and introduced in 2014.
I warn Members that that is much more difficult than integrating the NHS itself. The NHS in England has become really fragmented. It is important to put that back together before integrating it with social care. What integration stops is the arguments between acute care and social care about which purse the money comes out of to look after a particular patient, but there does have to be money in the purse to start with. In Scotland, we spend £163 a head more on health and £113 a head more on elderly social care. The money is needed to provide the service. Scotland is the one place in the United Kingdom where we provide free personal care, because we think it is cost-effective as a way of allowing people to stay at home.
The Minister says that these will be statutory bodies and that they are unlikely to be private companies. If that is what the Government believe, they should put it in legislation, because that removes any doubt or concern. The response to the consultation says that
“further requirements around financial controls, transparency and accountability will be developed before the ICP Contract is made available for use.”
When will that be? Will it be before contracts are put out? The transparency is critical. If any private companies are running ICPs, they will hide behind commercial sensitivity and will not be open to freedom of information. That would be unacceptable. What about their contracting, which is mentioned in this SI? Will section 75 be revoked so that we do not have a replay of what happened in Surrey, when commissioners tried to bring the new contract back to the NHS, were sued by Virgin for over £2 million and settled out of court?
If outsourcing continues, fragmentation rather than integration will continue. Will tariffs be abandoned because they reward admission to hospital, whereas the aim of this proposal is to support people at home? How will the components of an ICP between a main acute hospital, a small cottage hospital and social care or community services be funded? It may all sound very good if it is a gentleman’s agreement, but if one part of that system goes bankrupt because the financing system has not been changed, all bets will be off and all co-operation will disappear.
Social care is critical to this and Age UK says that well over 1 million people are not getting the social care that they need. It is necessary that the ICPs deliver prevention, early treatment, chronic disease management, acute care, mental health, social care and end of life. That is a lot of different players to bring together and it is important that the Government recognise that the Health and Social Care Act 2012 fragmented and blew apart the whole system. For integration to work, they need to admit that it failed, bring back proper legislation and put the system back together in a way that is wrapped around the patient, so that there is patient-centred, not budget-centred, care.
Sarah Newton (Truro and Falmouth) (Con)
Promoting integrated health and care services for my constituents in Cornwall has been a top priority for me since I was elected in 2010. I am delighted that promoting integrated care is a priority for the NHS long-term plan, enabling an NHS that is increasingly joined-up and co-ordinated, overcoming the traditional barriers between care institutions, teams and funding streams.
The NHS has been developing, testing and evaluating new models of care to integrate services for some time. I was delighted to support the Kernow clinical commissioning group to participate in the integrated care and support pilots, a precursor to the vanguard programme. The vanguard programme built on that work, and evaluation shows that the new models of care enabled more people to be cared for closer to home and at home, supported by joined-up services. That leads to fewer unplanned and emergency admissions to hospital.
That learning is enabling the further changes that this SI will make. I know from conversations that I have with local commissioners of health and care services that, too often, different funding streams, organisational structures and governance arrangements get in the way of commissioning patient-centred, joined-up services for people who need support from NHS primary and secondary care, as well as Cornwall Council. The integrated care contract that we are considering tonight has been carefully consulted upon and will give a new opportunity and more choice to local health and care professionals on how they can improve the services that they provide locally. No two communities are the same. Providing world-class health and care services to people in Cornwall needs a very different approach from the approach in Manchester. I welcome the intention of the SI to enable the right clinical, organisational and financial incentives for providers to collaborate to deliver preventive, proactive and co-ordinated healthcare for the communities that they serve. This is an important SI that will enable improved patient care and I am delighted to support it tonight.
Lyn Brown (West Ham) (Lab)
Should my Whip, who is not listening at the moment, wish me to sit down, he needs to indicate that to me and I will do exactly what I am told. The changes that we are discussing today are technical, but important. The creeping fragmentation and privatisation of our NHS, where more and more services are contracted out to unaccountable profit-making companies, has occurred precisely because of such obscure, technical changes.
My constituents need integrated care services across different organisations, as well as more preventive health and public health action. That is urgent, it should be a priority, and there should be legislation and full debate to make it happen. Currently, just 54% of my constituents—barely more than half—receive the breast cancer screenings they need. We have lower rates of physical activity than the national and London averages, as well as higher rates of smoking, and 44% of local children leave primary school obese. If the legislation we are talking about were just about joining up care for patients, creating genuine efficiency by avoiding duplication of services, or enabling patients to receive effective care closer to home in the community, rather than in hospital, I would absolutely welcome it.
Jonathan Ashworth
My hon. Friend is making an excellent speech, and I hope she continues to make an excellent speech. On the point about what is happening in east London, there is a very good integrated programme there for dealing with diabetes. The point is this: there are very good examples of integration taking place across the country without the need for this contract, which could usher in greater privatisation.
Lyn Brown
My hon. Friend is absolutely right. I believe, and I know he believes, that these changes are important and should not be done by statutory instrument. The goal of healthcare integration can and should be pursued with the full scrutiny provided by primary legislation.
Locally, these plans have raised huge concerns. Currently, Newham is in a sustainability and transformation partnership with seven other boroughs—Havering, Redbridge, Barking and Dagenham, Waltham Forest, Tower Hamlets, Hackney and the City of London. Those are really very different places, not only politically but in terms of age, ethnicity and levels of deprivation. Any integration plan that covers that wide an area will be incredibly difficult to get right.
I understand that the current thinking is more about dividing that eight-borough STP into three new integrated care systems, or ICSs. Newham will be lumped together with Waltham Forest and Tower Hamlets. I am very worried that pushing these areas together, with one extremely overstretched budget, will result in money being taken away from my constituents in Newham, whose needs are extremely high. If the Government were talking about enabling greater integration at local authority level, where democratically elected councillors could be properly involved, the issue would not be that much of a concern.
To be frank, I have absolutely no confidence that there would even be a proper consultation about integrating Newham into a three-borough ICS. I know that that is what local leaders expect only because I asked them about it before the debate. I am told that not one health body locally actually wanted to sign up to the STP—not one local body. But that did not matter to those who are really in control, so it was just put in place anyway as the East London Health & Care Partnership. This supposed partnership was given an incredibly complicated governance structure. Again, no one actually wanted it. That was not because health bodies do not want to collaborate; it was because this Government’s failed reforms do not have the confidence of clinicians.
There are many basic questions that need to be answered and that have not been. I have five for tonight. One, how do the Government plan to prevent fragmentation, given that there are so many different ways that these arrangements could be made? Two, how will existing borough-level partnerships slot into these new structures? Three, how are dedicated NHS staff, elected local representatives or even—horror!—patients themselves going to have control over how these structures are implemented, which areas are joined together and which services are included? Who will have that control?
Four, once one of these integrated bodies has been set up, what actual accountability will there be? As we know, public health and social care services are currently in the hands of councils. Even beyond that, many health and wellbeing objectives are the statutory responsibility of local councils too. Therein lies accountability to local people, but it is totally unclear to me how councillors will be able to hold the new ICPs to account in turn. If those new bodies are going to be responsible for making decisions, they should have to be transparent and accountable. I am not at all opposed to the integration of services, but we must create more accountability, and not risk losing the little that is currently there.
My fifth and final question is this. How will the Government guarantee to my constituents that this change will not become another back-door privatisation? How can they reassure me that the enormous, inefficient, profiteering “health maintenance organisation” monsters that exist in the United States will not be given a foothold here in exchange for, say, a trade deal post Brexit? This is what I find most offensive about the statutory instrument. Ministers have been offered the chance, time and again, to say that private companies will not be able to act as integrated care providers, and will not be able to bid for the huge contracts that will be created. But I have heard no good reason why the Government will not make those commitments.
Rosie Cooper (West Lancashire) (Lab)
The House of Commons Library recently confirmed that 26 health service contracts worth more than £128 million are currently out to tender, on the basis of legislation that NHS England recently urged the Government to repeal. Does my hon. Friend not think that private companies should be blocked from securing these contracts, and that the Government should deal with the counter- productive effect that these competition rules and powers have on the integrity of NHS care? There is a branch of Virgin Care in my local community. Someone who attends a podiatry appointment, for example, will be told that no qualified staff are on hand, but only people who can cut nails. It is outrageous that those people are being paid on the same basis as everyone else.
Lyn Brown
My hon. Friend is absolutely right. Private companies are able to work within the structure set out in primary legislation such as the 2012 Act. The Minister said in an interview that one of the reasons why we cannot have this in a Bill is that it would be too complicated to draft. As far as I can see, however, it is quite simple. The Government should bring forward new legislation to put these reforms on a proper transparent footing with full scrutiny, and should argue for the decisions that they want to make—including decisions about openness to private contractors, if that is something that, ideologically, they want to defend.
The Government should give the English electorate a plan that they can see and can judge for themselves. The Government should tell the electorate what they are doing with the NHS. My feeling is that their proposals are contained in an SI because they hoped that they would slip by, would not be seen and would not be judged, but I tell the Minister that he will be judged.
Question put.
The Deputy Speaker’s opinion as to the decision of the Question being challenged, the Division was deferred until Wednesday 20 March (Standing Order No. 41A).