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Blog

Integrated Care Systems – what do they mean for communities?

8/7/2021

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By Harry Leitch

In a series of guest blog posts by Harry Leitch, Integrated Care Systems will be explained, and key concerns highlighted. The question will then be asked, what do these changes mean for communities? 
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"Although seen by the media as suggesting the role of the private sector will be reduced, the proposed legislation, if passed, will enact the current government’s wish to further fragment, destabilise and privatise our NHS." - Keep Our NHS Public

During a pandemic that has revealed the necessity of universal, comprehensive and equitable healthcare, a top-down reorganisation of the NHS is underway. In accordance with proposals from the 2019 Long Term Plan, NHS England (NHSE) is transforming the NHS into Integrated Care Systems (ICS).

For Keep Our NHS Public (KONP) and other campaign groups, these moves represent a severe threat to the NHS and a failure to achieve the increased and sustained funding required. Key concerns include use of a population health perspective, lack of regulation and increase presence of private companies within the NHS.
What are ICS?
In sum, ICS are collaborations between NHS providers and commissioners that bring together local authorities and other partners within a defined geographical area. Together, they plan how care and health services will serve the needs of populations. NHS trusts and foundation trusts will both become members of local ICS and form partnerships with other providers within the system. 

ICS are defined by NHS England as: ‘NHS organisations, in partnership with local councils and others, take collective responsibility for managing resources, delivering NHS standards, and improving the health of the population they serve’.
  • The backdrop to ICS includes the 2012 Health and Social Care Act (HCSA), which established a competitive market within the NHS. Today, the market system is still in place, but ‘competition’ is to be replaced by ‘integration’ of the NHS with local authorities and other service providers -- largely private companies (KONP, 2020). This process has fragmented the NHS into 42 separate ICS (NHSE, 2021b). 
  • NHS planning guidance identifies two key functions of ICS: (1) ‘coordination of system transformation’, where partners agree to changes in health and care services, and (2) ‘collective management of system performance’ in which partners collectively manage the financial and operational performance across the system (NHS Providers, 2020). 
  • Within an ICS exists one single budget that partners collectively decide how to allocate (KONP, 2020). The ICS model involves a perspective change towards a ‘population health’ approach, differing from clinically-led decisions that focused on individual need in the past (King’s Fund, 2021). Instead, budgeting is informed by large datasets from the NHS and beyond that are used to identify population health needs (KONP, 2020; Graphnet, 2021). Data is used to predict healthcare journeys and determine what interventions are directed to who within a population (NHS SCW, 2021). 
  • ICS are based on a three-tiered model, in which three levels are defined: system, place and neighbourhood (King’s Fund, 2021). 
  • ICS are based on an American model of healthcare systems (KONP, 2018). 

The case for ICS
Key driving forces for the changes to healthcare as part of ICS are the increasing number of elderly people and people with long-term conditions that require care. A need for reduced barriers to services and increased care in the community has been identified, and ICS have been suggested to offer a solution (King’s Fund, 2021). It is claimed that ICS will overcome traditional divisions in care and limit the ‘disjointed care’ that many people have experienced previously (NHSE, 2021a). A crucial aim of ICS is also to reduce inequalities between different groups in society, as well as create new partnerships between health and care providers (NHSE, 2021a). 

It must be noted that whilst the aims of ICS appear positive and the related demographic changes are undeniable, campaigners have highlighted a series of concerns. 

Key Concerns 
Whilst upholding the marketisation of the NHS, ICS are internally managed in a manner that furthers privatisation. The following examples paint a picture of increasing privatisation as part of ICS and reveal changes to the running of NHS services upon which communities depend. 

Population Health Perspective
This approach depends heavily on mass collection of data from a range of care settings in order to inform budgeting. The aim is to cut patient ‘demand’ and increase cost-effectiveness, with the focus of the NHS shifting towards achieving data targets for populations (KONP, 2020).

​According to the definition of population health management provided by Deloitte - who are highly involved in provision of these services - changes in patterns of service delivery, alongside new clinical positions and ‘flexible’ working are key. Importantly, research has indicated that a population health management approach is not effective in reducing demand or costs of services (KONP, 2021).


Patients are also expected to become more ‘self-sufficient’ in the management of their own care, to adopt more pro-health behaviours and improve medication adherence whilst also becoming more ‘health literate’ (Deloitte, 2019). This model anticipates a change in healthcare in which patients expect less from health services and the private sector is able to exploit new areas as they open up (Patients4NHS, 2021). 

Furthermore, the increased access of private companies to NHS patient data will be achieved through the contracting out of population health management. This data is highly valuable to private companies for the purposes of research and product development (Patients4NHS, 2021). It is not yet clear how this level of data access will interact with patient consent or confidentiality. Importantly, population health management creates the databases required by health insurance providers within private healthcare systems (Patients4NHS, 2021). 

  • Some people with disabilities and mental health needs require long-term support to stay well (Kessler et al., 2005). How will a population health perspective meet their needs and how can the expectation of ‘self-sufficiency’ be applied to vulnerable people? 
  • Structural factors keep many in a cycle of hardship and vulnerability (World Health Organisation, 2010), whilst the pandemic has further increased poverty, housing and financial insecurity (McKinsey, 2020). Is it justifiable that self-management of care be applied to those already struggling?
  • People in marginalised groups face severe health inequalities. For example, among poorer people, there is a greater likelihood of suffering long-term physical and mental health conditions (King’s Fund, 2012).  By focusing on the level of the population, will this perspective reinforce these inequalities? 
  • Concern exists over the use of algorithms to allocate healthcare based on population data, with evidence revealing racial biases contained in US health algorithms that negatively impacted access to services among Black patients (Obermeyer et al., 2019). Is there potential for structural racism to be perpetuated through algorithmically informed decisions within a population health perspective? 

Lack of regulation 
Suggested changes to the law involve converting the NHS into an unregulated market. Proposals include recommendations that NHS services are exempt from Public Contracts Regulations 2015, which is intended to provide greater discretion to commissioners when procuring services (KONP, 2020). This would mean that ICS could choose to overlook formal procurement processes, making it legal for contracts to be handed out based on personal relationships in a corrupt manner (Wortley, 2021). Such changes are particularly significant when considered alongside the aim of NHS England to allow each ICS independence when appointing its governing board; a move that would enable boards to include representatives from private providers (KONP, 2020).
  • During the pandemic, the issuing of contracts to politically connected companies has been tied to waste and negligence (The New York Times, 2020). Is it justifiable that the proposed changes will make it easier contracts to be made without transparency?

Private companies and patient care
ICS are based on provider collaboratives between NHS organisations and others. Yet, the make up of these collaboratives is not under scrutiny or control. The possibility therefore exists that providers in these collaboratives may be private companies with no connection to local communities. 
  • Previously, a number of corporations have withdrawn from or had their contracts terminated with the NHS, negatively impacting patient care and treatment access (Lowdown NHS, 2019). By increasing the presence of private companies, are patients being made more vulnerable to this negative outcome?

The problem with private suppliers 
As part of ICS management and development, fast and easy access to private suppliers has been established. NHS England has created the Health Systems Support Framework (HSSF), a framework enabling quick access to private suppliers.  The HSSF contains a list of 83 companies accredited to provide services. Of these suppliers, 76 are private companies, a third of which are American and include IBM, McKinsey, Deloitte, Cerner and Centene (KONP, 2020).

The framework contracts allow companies to be used in place of NHS management when creating policy and making decisions. Services available for these contracts include electronic patient records systems, patient empowerment, demand management, medicines optimisation and many others (NHSE, 2021). 
  • During the pandemic, several scandals have involved private companies exploiting the need for PPE for profit during the pandemic (BMJ, 2021). With marketisation and increased presence of private stakeholders in NHS supply chains, is this to become the status-quo? 

Final Thoughts
Understanding ICS and its implications can be challenging. Jargon and misleading use of language makes this subject less much less accessible. Nonetheless, concerns such as increasing the scope for privatisation hold serious implications for communities. It is crucial that campaign efforts increase awareness and understanding around ICS.

Below are a series of actions that you can take to contribute to the KONP campaign. 
  • Support and collaborate with KONP
  • Sign the petition 'Stop ICS roll out in England' 
  • Use KNOP's template letter and write to your MP and councillors
  • Use the KONP model motion for the Labour Party and Trade Unions
  • Educate others, especially NHS professionals
  • Share concerns and raise awareness 
  • Follow KONP on @keepnhspublic for updates
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Author
Harry
 Leitch works within Camden and Islington NHS Trust as an Assistant Psychologist. Passionate about perspectives that understand mental health within its socio-political context, they joined Psychologists for Social Change in 2019. They also campaign for Keep Our NHS Public and the Socialist Health Alliance. 
​
Reference List
  • BMJ. (2021). The UK’s PPE procurement scandal reminds us why we need ways to hold ministers to account. Retrieved 12 May 2021, from https://www.bmj.com/content/372/bmj.n639.
  • Deloitte. (2019). The transition to integrated care Population health management in England. Www2.deloitte.com. Retrieved 12 May 2021, from https://www2.deloitte.com/content/dam/Deloitte/uk/Documents/public-sector/deloitte-uk-public-sector-population-health-management.pdf.
  • Graphnet. (2021). Population health. Graphnethealth.com. Retrieved 12 May 2021, from https://www.graphnethealth.com/solutions/population-health/.
  • KONP. (2020). Integrated Care Systems: The threat to the NHS, social care and public health. Retrieved 12 May 2021, from https://keepournhspublic.com/campaigns/legislative-changes/integrated-care/threat-nhs-social-public/.
  • Kessler, R., Berglund, P., Demler, O., Jin, R., Merikangas, K., & Walters, E. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives Of General Psychiatry, 62(6), 593. https://doi.org/10.1001/archpsyc.62.6.593
  • King's Fund. (2012). Long-term conditions and mental health - The cost of co-morbidities. Retrieved 12 May 2021, from https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/long-term-conditions-mental-health-cost-comorbidities-naylor-feb12.pdf.
  • King's Fund. (2021). Integrated care systems explained. The King's Fund. Retrieved 12 May 2021, from https://www.kingsfund.org.uk/publications/integrated-care-systems-explained.
  • KONP. (2018). Keepournhspublic.com. Retrieved 12 May 2021, from https://keepournhspublic.com/wp-content/uploads/2018/03/KONP-Briefing-Paper-Integrated-Care-ACOs-ACSs-updated-2018-03-20.pdf.
  • KONP. (2021). Integrated Care Systems: The threat to the NHS, social care and public health. Keep Our NHS Public. Retrieved 12 May 2021, from https://keepournhspublic.com/campaigns/legislative-changes/integrated-care/threat-nhs-social-public/.
  • Lowdown NHS. (2019). 50 contract failures found in NHS outsourcing review (2013-2019) - The Lowdown. The Lowdown. Retrieved 12 May 2021, from https://lowdownnhs.info/explainers/50-failures-in-nhs-outsourcing-2013-2019/.
  • McKinsey. (2020). COVID-19 in the United Kingdom: Assessing jobs at risk and the impact on people and places. Retrieved 12 May 2021, from https://www.mckinsey.com/industries/public-and-social-sector/our-insights/covid-19-in-the-united-kingdom-assessing-jobs-at-risk-and-the-impact-on-people-and-places.
  • NHS England. (2021a). NHS England » What are integrated care systems?. England.nhs.uk. Retrieved 12 May 2021, from https://www.england.nhs.uk/integratedcare/what-is-integrated-care/.
  • NHS England. (2021b). NHS England » Scope of Framework. England.nhs.uk. Retrieved 12 May 2021, from https://www.england.nhs.uk/hssf/use-framework/.
  • NHS England. (2020). NHS England » NHS achieves key Long Term Plan commitment to roll out integrated care systems across England. England.nhs.uk. Retrieved 12 May 2021, from https://www.england.nhs.uk/2021/03/nhs-achieves-key-long-term-plan-commitment-to-roll-out-integrated-care-systems-across-england/.
  • NHS SCW. (2021). Population health analytics. NHS SCW Support and Transformation for Health and Care. Retrieved 23 June 2021, from https://www.scwcsu.nhs.uk/services/population-health-analytics. 
  • NHS Providers. (2020). Nhsproviders.org. Retrieved 12 May 2021, from https://nhsproviders.org/media/689134/otdb-planning-guidance.pdf.
  • Obermeyer, Z., Powers, B., Vogeli, C., & Mullainathan, S. (2019). Dissecting racial bias in an algorithm used to manage the health of populations. Science, 366(6464), 447-453. https://doi.org/10.1126/science.aax2342
  • Patients 4 NHS. (2021). Integrated Care Systems. Patients4NHS. Retrieved 12 May 2021, from https://www.patients4nhs.org.uk/accountable-care-systems/.
  • Pollock, A., & Roderick, P. (2021). Integrating care: Next steps to building strong and effective integrated care systems across England. Retrieved 12 May 2021, from https://allysonpollock.com/wp-content/uploads/2021/01/AP_2021_Pollock_ICSNextStepsConsultation.pdf.
  • Waste, Negligence and Cronyism: Inside Britain’s Pandemic Spending. Nytimes.com. (2020). Retrieved 12 May 2021, from https://www.nytimes.com/interactive/2020/12/17/world/europe/britain-covid-contracts.html.
  • World Health Organisation. (2012). Who.int. Retrieved 12 May 2021, from https://www.who.int/sdhconference/resources/ConceptualframeworkforactiononSDH_eng.pdf
  • Wortley, P. (2021). Written Evidence: White Paper on Health and Social Care. Committees.parliament.uk. Retrieved 12 May 2021, from https://committees.parliament.uk/writtenevidence/25009/pdf/.
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