Ten years ago, Andrew Lansley’s health and social care bill to reorganise the NHS in England faced enormous opposition. The current health and care bill, which has its second reading in the House of Lords today, has received far less attention. But it is no less significant. The new bill will continue the dismantling of the NHS, this time by adopting more features from the US health system. For anyone who cares about the NHS, this should set off alarm bells.
The proposals mean that for the first time since 1948, parliament will not determine to whom NHS services must be provided. The bill removes the requirement for emergency services to be provided for everybody present in an area. No explanation has been given for getting rid of it.
Over the past three decades the funding, planning and provision of health services have become disconnected from each other and from people living in local areas. The bill takes this further. It gives a single budget pot to 42 new integrated care boards (ICBs) to commission most health services. These won’t serve all people living in a local area, but a “group of people” who can be drawn from anywhere in England. The group will be allocated to the ICB under rules made by NHS England, without parliamentary process.
Each ICB will have “core responsibility” for its group of people. This new concept closely resembles the US definition of a health maintenance organisation (HMO). In the US, contrary to popular perception, the government funds most healthcare, much of it through private health companies such as HMOs and other “managed care organisations”. These are responsible only for providing limited free services to a group of people who enrol as their “members”, not a local population. They provide a core or basic package of care paid for under a health plan. Additional services are paid for through more insurance or user charges.
US private health companies such as Centene (Operose) and UnitedHealth (Optum Health) offer publicly funded health plans in the US, and already operate in the NHS. After a takeover earlier this year, Centene became one of the largest primary care providers in England, with 58 practices and more than 500,000 patients. Within weeks of the deal, Samantha Jones, the CEO of Centene in the UK, had resigned and was appointed Boris Johnson’s health adviser. UnitedHealth has received a range of NHS contracts for more than a decade, and in 2019 Optum was one of two companies awarded a four-year prescribing support contract up to £100m. The chief executive of NHS England was until recently Simon Stevens, the former vice-president of UnitedHealth. Stevens became a peer this year, and the bill is his brainchild.
After a weasel-worded amendment from the government, which failed to rule out private companies sitting on the ICBs or their committees, the new bill will still allow these multinationals, together with private health insurance companies such as Bupa and Spire, to join the ICBs. These ICBs will decide how the budget should be distributed.
Still, despite the focus on ICBs, much of the real power and decision-making will lie with four groups that already exist but are not mentioned in the bill: provider collaboratives, place-based partnerships, primary care networks, and companies accredited to the Health System Support Framework. Provider collaboratives are groups of public and private providers that NHS England has said will be responsible for designing services. ICBs will be able to delegate their functions to them. The bill also proposes that commissioning contracts can include “discretions … in relation to anything to be provided under” the contracts. In practice this will allow providers to decide what, where and how services will be provided. So much for our so-called rights under the NHS constitution.
More than 40 collaboratives are listed on the NHS England website, including several private companies such as Cygnet, Priory and Elysium. There are echoes here again of the US. In the byzantine US healthcare system, private insurance companies sell health plans to individuals, some of whom may be eligible for public funding. The private insurance companies enter contracts with a limited number of providers to buy services for their plan members, known as “provider networks”. An ICB will be able to operate similarly, with similar effects, for its group of people. The Northern Care Alliance is already reported to be doing this. In effect, this leaves the principle of a universal and comprehensive NHS in tatters.
And let’s not forget the many private companies already accredited to the health system support framework, including Atos, Capita, Operose, Deloitte, Ernst & Young, McKinsey, PWC, Serco and Optum. The bill says nothing about these, but they will be providing population health management, digital and other support services. In other words, the private sector will be present at every level of the health service.