The government's push for integrated care in the NHS is stirring up huge controversy. In the past few years plans to introduce Accountable Care Organisations have emerged, which immediately sparked connections for health campaigners between these new organisations and bodies of the same name that exist in the United States.
Accusations were made that ACOs signalled a radical move towards an insurance-based system. A court case against the government was launched involving one of the plan’s most prominent critics, Prof Stephen Hawking, which forced the government to announce a pause, to consult with the public.
NHS England tried to head off the associations with the USA by changing the name from ACO to Integrated Care Organisation or ICO, but this has had little impact.
In the NHS long-term plan published in January 2019, the Government reiterated its plans for integrated care and used the term Integrated Care Systems (ICS). The term ICS is used to describe a range of care models, from close partnerships between organisations through to a single organisation being in control of integration; the latter is in effect an ICO.
Integrated care is a complicated area, this page aims to answer some common questions on this area.
Integrated Care Q&A
Integrated care is a concept which encourages organisations to work together under a single plan. It can involve sharing budgets and merging functions, but it is not a new concept and many countries have been experimenting with it in their healthcare systems.
The NHS has been working on various forms of integration within certain geographical areas for many years. What is different now is that according to the NHS ten-year long-term plan released in January 2019, the development of integrated care is the top priority and integrated care systems (ICS) must be in place across England by 2021.
One source of confusion when discussing integrated care is the plethora of terms used, including accountable care organisation (ACO) and system (ACS), integrated care organisation (ICO), and multispeciality community partnership (MCP).
In the long-term plan, NHS England refers to integrated care systems as a catch-all term that covers a range of integrated care models that are in development.
The January 2019 NHS long-term plan has as a key component the formation of around 42 integrated care systems (ICS) across England. In this document NHS England use ICS as a more general term to cover several forms of integrated care.
All forms of ICS, according to NHS England, should involve NHS organisations, local authorities and other non-NHS organisations providing health and social care, working more closely together.
The long-term plan states that by April 2021 ICSs will cover the whole country: these will grow out of the current network of STPs. Each ICS will involve a single Clinical Commissioning Group (CCG).
Every ICS will have:
- a partnership board, drawn from and representing commissioners, trusts, primary care networks, and possibly local authorities, the voluntary and community sector and other partners;
- a non-executive chair (locally appointed, but subject to approval by NHS England and NHS Improvement) and arrangements for involving non-executive members of boards/ governing bodies;
- sufficient clinical and management capacity drawn from across their constituent organisations to enable them to implement agreed system-wide changes;
- full engagement with primary care, including through a named accountable Clinical Director of each primary care network.
There will be reform in funding models and a new contract to support ICSs.
The NHS long-term plan outlines two types of contractual working in integrated care:
- an ICS can be delivered locally through collaborative arrangements between different providers, including local ‘alliance’ contracts, or;
- another option is to give one lead provider responsibility for the integration of services for a population: in this case the provider will use a new Integrated Care Provider (ICP) contract. The ICP contract will allow the contractual integration of primary medical services with other services, and, according to NHS England, creates greater flexibility to achieve full integration of care.
The ICP is equivalent to an Integrated Care Organisation (ICO), a term that has been used in the past.
1. Why rush forward with integrated care systems (ICS) and integrated care providers (ICPs) when there is yet to be any real evidence that they will work? It is only 7 years since the last major re-organisation, which has been widely criticised.
2. Why continue to allow private companies the opportunity to take control of such a major role? Their record in running NHS services included many examples of contracts that have failed. If this is not the intention why not just rule it out completely.
3. If ICPs are given a fixed budget under their contract, what happens when they run out of money, who goes without care and how is this decided?
4. ICPs are destined to fail unless proper funding is restored, the same is also true of any other form of integration.
5. Does this version of integration really fit with the key principles of the NHS - e.g., How can we make sure that healthcare remains free at the point of use, when more of it will be provided in the community where means-tested social care already exists?
The STP (sustainability and transformation partnerships) plans published in 2016 initiated the accelerated development of integrated care systems (ICS) across the country and by early 2019 these have reached various stages of development.
In January 2019, the new NHS long-term plan announced that by 2021 all of the NHS in England will be developed as integrated care systems (ICSs), with approximately 42 ICS. These ICS will develop out of the STP areas.
Although the development of ICSs has been ongoing for several years now, no ICS is actually up and running yet. The most advanced areas are Dudley and Greater Manchester, both of which were planning to launch a new integrated care provider in April 2018, however development has now been delayed in both areas.
In January 2019, it was reported that the development of a new integrated care organisation, known as an integrated care trust, in Dudley has been delayed until 2020. The area has almost completely concluded its procurement, but the complicated contractual arrangements have delayed implementation. In 2018, it was announced that Dudley's main acute trust, the Dudley Group Foundation Trust, would be split in two, leaving a residual acute trust and creating a new multispecialty community provider (MCP), which would hold the integrated MCP contract (this will be the ICP contract).
In 2017, NHS England announced several areas as being targeted for development into integrated care systems, as a result these should be ahead of others in terms of development, including the following:
- Frimley Health including Slough, Surrey Heath and Aldershot;
- South Yorkshire & Bassetlaw, covering Barnsley, Bassetlaw, Doncaster, Rotherham, and Sheffield;
- Nottinghamshire;
- Blackpool & Fylde Coast with the potential to spread to other parts of the Lancashire and South Cumbria at a later stage;
- Dorset;
- Luton, with Milton Keynes and Bedfordshire;
- Berkshire West, covering Reading, Newbury and Wokingham;
- Buckinghamshire.
In the NHS long-term plan published in January 2019, NHS England talks of integrated care systems (ICS) being either delivered:
- locally through collaborative arrangements between different providers, including local ‘alliance’ contracts;
- or, with one lead provider given responsibility for the integration of services for a population. In this case a new Integrated Care Provider (ICP) contract will be used.
An ICP generally refers to a care model where healthcare is run under a single contract by a single organisation. The contract could be awarded following a competitive tendering process. This process is open to all organisations - NHS, for-profit private companies and third sector organisations.
Despite the long-term plan stating:
“We expect that ICP contracts would be held by public statutory providers.”
There is no legislation at present that prevents an ICP contract being awarded to a private for-profit company. So an ICP contract could effectively hand over the legal responsibility for provision of universal healthcare in an area to a private company.
Furthermore, there is no limit on how much of an ICP’s work could be sliced off and profitably sub-contracted to private corporations.
It is not clear in the long-term plan, published in January 2019, how funding for integrated care systems will be organised.
It is possible that the holder of an ICP contract will be provided with a fixed or capitated budget. From this budget the contract holder will have to provide (either by itself or via sub-contracts) all health and social care required in its area under the contract.
This type of contract in other areas of the world, including the USA and Spain, where they are known as ACOs (accountable care organisations), often allow the holder of the contract to keep a certain percentage of unspent budget or ‘profits’. In theory, this type of profit-sharing incentive is meant to lead to efficiencies and a focus on improving population health to reduce costly procedures, in particular hospital care and A&E admissions.
Originally the government had intended to introduce primary legislation for integrated care, but it changed these plans after the 2017 election substantially weakened its Parliamentary position. Subsequently it has been trying to proceed by changing regulations (secondary legislation) - leaving many of the existing organisations and structures in place, however the legality of this approach has been challenged.
In order for an fully integrated care systems (ICS) to be put in place a new contract needed to be available for the commissioners to use. In August 2017, a draft integrated care provider (ICP) contract was published, designed to allow Clinical Commissioning Groups (CCGs) to choose to commission ICPs in their areas.
This contract publication was followed by a two month consultation on the draft contract. At this point it became clear that before the contract could be used, secondary legislation would be needed to amend the Health and Social Care Act 2012.
At the start of January 2018, the secondary legislation needed was expected to be put in place in February 2018 thereby allowing the first ICPs to start in April 2018. However, in January 2018 Sarah Wollaston MP chair of the Commons Health Committee wrote to Jeremy Hunt asking that any moves to implement ICPs be paused pending further consultation. Prior to this legal challenges to the setting up of ICPs had been filed. Both the letter and the legal challenges resulted in a delay to the legislation.
In late January 2018, Jeremy Hunt wrote to the chair of the Commons Health Committee saying that the ICP contract implementation would be paused allowing for more consultation. NHS England was forced to conduct further public consultation work on the ICP contract.
NHS England's consultation opened 3 August 2018 and closed 26 October 2018.
From the January 2019 NHS long-term plan, it is clear that there are still legislative issues surrounding the development of ICS and ICP. NHS England called upon the Government to amend legislation in the 2012 Health and Social Care Act to allow providers, such as trusts and other organisations, to be able to collaborate. The request includes introducing legal “shared duties” for clinical commissioning groups and NHS providers on outcomes and finance and allowing foundation trusts to create joint committees, allowing “the creation of a joint commissioner/provider committee in every integrated care system”.
In other areas of the world, Accountable Care Organisations operate with a capitated or fixed annual budget that allows the providers to retain and share any savings made. It is unclear how budgeting for integrated care systems and integrated care providers will operate as yet, but a fixed budget is a possibility.
This type of approach has led to concerns that services will be rationed either because the budget provided is just not enough to provide all universal healthcare services or, and this is particularly pertinent if the contract holder is a private company, to produce savings to increase the amount of budget that the providers can retain as profit.
Rationing services also encourages people to seek private alternatives, which in turn reduces the budget spend under the integrated care system, potentially leading to higher ‘profits’.
Two legal challenges against the establishment of ACOs (as they were previously known) have taken place. When they began in early 2018, NHS England agreed to a pause on the development of ACOs to allow for a 12 week consultation procedure. The consultation concluded in October 2018.
999 Call for the NHS
The campaign group 999 Call for the NHS, backed by law firm Leigh Day, lodged a judicial review in October 2017. This claims that the contract for accountable care organisations breaches the Health and Social Care Act 2012.
The papers claim that the formation of ACOs breaches section 115 and 116 of the 2012 Act, which relate to the price a commissioner pays for NHS services and regulations around the national tariff.
The campaigners’ case argues that under current legislation, prices paid for NHS services must reflect how many patients receive the care under that specific service, whereas the ACO contract allows commissioners to give providers a fixed budget for the population in the area.
The judicial review was given permission to proceed in late December 2017 and it was heard 24 April 2018.
The Judge Mr Justice Kerr ruled that the court did not find anything unlawful with the payment mechanism proposed by the ACO contract.
The judgement said that the objection in the case was a political objection to the payment mechanism and therefore it "is not a matter for the court.”
The campaign group said it would appeal the decision.
JR4NHS
The second application for a judicial review was lodged on 11 December 2017 by Dr Graham Winyard, Dr Colin Hutchinson, Allyson Pollock and Sue Richards, and Professor Stephen Hawking, under the campaign name JR4NHS.
The academics are working with Harrison Grant Solicitors and Nigel Pleming QC to argue that introducing new commercial, non-NHS bodies (ACOs) to run health and social care services without proper public consultation and without full Parliamentary scrutiny would be unlawful. They argue that the consultation procedure around the ACO contract was insufficient.
In early July 2018, the judge, Mr Justice Green, ruled that the policy was “lawful” however the health and social care secretary Jeremy Hunt was “under a duty” to consider criticism against ACOs when it goes to public consultation.
The High Court held that the policy falls within the “statutory powers of a clinical commissioning group” and is “not contrary to the ‘commissioner-provider split’ under the National Health Service Act 2006”.
The campaign has decided not to appeal the decision.
