Integrated Care System
Demand for democratic control in new Integrated Care System for NHS and social care dominates Devon County Council cabinet discussion
A passionate demand by Labour Councillor, Hilary Ackland (below), for greater democratic control in the new Integrated Care System for health and social care made a major impact as Devon County Council’s Cabinet finally considered the proposals which the Clinical Commissioning Groups have been developing since September.
Cllr Ackland said that a revamped Health and Wellbeing Board should be an Integrated Commissioning Board with decision-making powers in the new system, and proposed broader, cross-party representation.
I agreed that ‘democratic control is not an optional extra’, and said that governance proposals should be discussed before the Council approved the system. Replying, the opportunity for greater democratic input into the local NHS was emphasised by Chief Executive, Phil Norrey. Conservative Cabinet member, Cllr Andrew Leadbetter, had proposed a paper which agreed that governance issues needed to be addressed but made no specific proposals. The issue will now go to Health Scrutiny, hopefully on 22nd March.
In my speech, I welcomed the CCGs’ retreat from the idea of an Accountable Care Organisation, for which I said the judicial review joined by Stephen Hawking, as well as the hung parliament and local campaigners’ pressure, should take the credit.
- I also drew attention to uncertainty about how the financial organisation of the new system will impact on chronic failures of patient care.
- I warned that attempts to equalise funding between areas of the county could lead to even sharper cuts in Eastern Devon.
- I pointed out that the CCGs, even after 6 months, had failed to produce a single paper describing the Local Care Partnerships which are a key element of the system.
- The paper called for ‘public engagement’ – but there has been none, and even councillors do not understand the proposals.
I called for a delay in decisions until fuller information on all these points, as well as governance, was available. But the Cabinet unanimously adopted the proposals as they stood – the issues will go to Scrutiny before coming to full Council.
The debate is at 1.44, resumed at 2.22, in the webcast.
Our pressure has led to Devon NHS joining a national retreat from privatising Accountable Care Organisations. However the Devon Integrated Care System will still cap care, with weak democratic control – we need time to rethink
Regular readers will be aware that Devon has been following NHS England’s plan to get Sustainability and Transformation Plans or Partnerships (STPs: Devon’s is the successor to the ‘Success Regime’ which cut our community hospital beds) to ‘evolve’ into Accountable Care Systems (ACSs) which in turn will prepare to establish Accountable Care Organisations (ACOs).
Under ACOs, single organisations could be contracted to provide all services in an area for 10 years or more, and these organisations could – Jeremy Hunt has confirmed this to Sarah Wollaston – just as well be private companies as NHS bodies. So all of Devon’s NHS could have ended up being run by Virgin Care – or a US care conglomerate under Theresa May’s desired trade agreement with Donald Trump.
As recently as December 2017, Dr Tim Burke, Chair of Northern, Eastern and Western (NEW) Devon Clinical Commissioning Group (CCG), endorsed a ‘route map‘ for Devon’s ACS which said that in the ACS, ‘The Accountable Care Delivery System will hold the capitated budget for the population covered’, and that the aim is ‘through bringing budgets together on a whole population and/or model of care basis, [to] provide signals to providers on how to organise. This will signal the number, shape and scope of accountable care organisations and how they will need to work together to deliver.’
Devon backs off ACOs
Devon’s CCGs still want to set up an ACS – now rebranded an Integrated Care System (ICS). However in February they said: ‘A few areas in England are on their way to establishing an Accountable Care Organisation (ACO), where a single organisation is responsible for planning and delivering services to the whole population. This is not being considered in Devon.’
They are not the only ones to back off ACOs – indeed this week Kernow CCG went further and rejected the option of setting up an ICS under the overall control of the Cornwall Council CEO. Instead they voted for S75 partnership agreements for integration of NHS and social care, which have the advantage of being lawful as they’re mandated by the NHS 2006 Act. (Devon County Council already has a partnership agreement with the CCGs.)
Last Wednesday, the CCGs told Devon’s Health and Wellbeing Board that a ‘shadow’ ICS which will operate from 1st April, which they hope to be part of the next wave of formal ICSs to be recognised by NHS England. Within this, they aim to set up one Devon-wide ‘care partnership’ for mental health and four ‘local care partnerships‘ for Northern, Eastern, Southern and Western Devon. These will have boards with local government representatives (district and county councillors) as well as representatives of acute, primary care and mental health providers, and will engage with wider stakeholders such as the voluntary sector.
A victory for legal action and local pressure
It appears the retreat is genuine – and national. A Northumberland County Council Cabinet paper says ‘it now seems clear that no ACOs will be created nationally in the near future, as a result in a shift of national policy.’ It also says, ‘The original plans for the ACO are not now proceeding. Discussions are ongoing with NHS England, NHS Improvement and local system leaders about how organisational relationships might now develop to support the integration of services, however the timetable for and nature of any new arrangements remains unclear.’
I am authoritatively informed that this shift results from the impossibility of new legislation to allow ACOs to be created (a result of the hung parliament!). This is very interesting: it implies that while currently NHS England is still defending the crowdfunded judicial review of its draft ACO contract, it is already recognising that ACOs cannot be introduced in England under present legislation. It seems likely that full ACOs may only happen if the Tories regain a parliamentary majority. We shall have to see how precisely the legal challenge develops, but the retreat is already a significant victory for the legal action – and for the local pressure which I, other councillors and Save Our Hospital Services campaigners have mounted in Devon.
Lack of democracy in the development of the ICS
This leaves us with the proposed Devon ICS – and the undemocratic process of its introduction. A proposal is finally being put to DCC’s Cabinet this Wednesday, but since the Council itself will not meet until after 1st April, the CCGs will introduce the ICS without the approval of DCC, whose logo they have been using to advertise the idea since September. The Health and Adult Care Scrutiny Committee, which is supposed to examine important developments in the local NHS, is only discussing it on 22nd March, nine days before the ICS starts, its chair having disregarded the agreement that a special meeting should be held if the ICS was going ahead on 1st April!
This is the result of the lamentable failure of the Council’s Conservative leadership to bring the proposals to Council over the last 6 months. Would they even have been discussing it now, if I – a backbench councillor from the smallest opposition group – had not put it on the agenda of Health Scrutiny on 25th January? Or would they just have joined it without direct authority, as they did with the STP – after the Council rejected the Success Regime in December 2016, DCC officers (presumably with informal Cabinet authorisation) simply participated in the STP following the general duty of the Council to cooperate with the CCGs as statutory NHS organisations?
Problems with the proposed ICS
- The ICS will be based on capitated funding, which means that Devon NHS patients will be entitled only to the services which the CCGs decide they can have within their financial envelope. This is embedding the existing postcode lottery in the NHS, and another major step away from a universal national service.
- In the current situation, capitated funding is capitated underfunding, and threatens to further embed current dire shortfalls in service – as I pointed out at the last Health Scrutiny, all Devon’s four acute trusts were further away from meeting official targets for A&E, cancer care and routine operations in January 2018 than 12 months previously. Better-off patients will continue to be pushed towards private practice leaving the rest with a second-class NHS.
- The CCGs intend to apply capitation to each of Devon’s four areas, calling it ‘fair funding’ which is really equality of misery. Since Eastern Devon is ‘overfunded’ compared to Western Devon, watch out for a sharper deterioration in the east.
- Since the CCGs intend to apply for formal recognition as an ICS, which will bring them greater local financial flexibility, we need to know how they will use this.
- Commissioning power for all Devon’s NHS will be concentrated in the hands of a single Strategic Commissioner, who will be responsible only to the combined boards of the two CCGs. The CCGs say they don’t want to set up an ‘undemocratic organisation’ – but they are undemocratic organisations, with power concentrated in the hands of a few professional managers and selected doctors, and a single commissioner will concentrate undemocratic power further.
- There is no clarity on how NHS and DCC funding will be combined. There is a danger that adult social care, which is currently run by DCC, will increasingly be taken over by the CCGs, diminishing democratic control.
- Local care partnerships have been a fundamental part of the new system since it was first agreed by the CCGs in September, but despite this no paper has yet been published to elaborate this element, so we are being asked to approve a vague idea.
What needs to happen now
- DCC’s Cabinet cannot approve these proposals at this stage.
- Full proposals – including proper details of the Local Care Partnerships – should go to Health Scrutiny first, and then back to Cabinet at its next meeting, and finally to Council later in the summer.
- We need an explanation of how Devon patients can regain national standards of care while introducing this system.
- Proposals for strengthening democratic control, including the role of DCC and other councils, in the ICS should be brought forward first.
- Meanwhile, DCC officers can cooperate under their existing S75 partnership with the NHS.
- Nothing will be lost by a delay in bringing these proposals to Council, but that will not only enable proper scrutiny by Council, but will also allow the public to join the discussion.
- After Scrutiny and Cabinet have further considered the proposals, DCC and the CCGs should produce a document explaining these developments to the public and invite public debate on them.