Health and Care Bill

Written evidence submitted by Paula Riseborough (HCB34)

I’d like to submit my views on the Health and Care Bill 2021 based on my experiences of 34 years of working in the NHS as an allied health professional (now retired), as an NHS patient and supporter of those undergoing care, and as a campaigner for the NHS to remain a publicly funded and publicly provided health service, with healthcare free at the point of delivery.

1. No clear need for yet another re-organisation of the NHS

The aim of integrating health and social care systems and pathways is a laudable one but it doesn’t require a complete re-organisation of the NHS and social care into 42 Integrated Care Systems in order to achieve this. Progress towards achieving this has been taking place for many years through the hard work of primary, secondary and tertiary care practitioners and their liaison with local authorities and social care providers. In my view, the main barriers to further progress of this effort were and remain:

· Insufficient government funding for the NHS and social care 2010-2019:

‘During the period of austerity that followed the 2008 economic crash, the Department of Health and Social Care budget continued to grow but at a slower pace than in previous years. Budgets rose by 1.4 per cent each year on average (adjusting for inflation) in the 10 years between 2009/10 to 2018/19, compared to the 3.7 per cent average rises since the NHS was established.’

Ref: The NHS budget and how it has changed | The King's Fund (kingsfund.org.uk)

· Poor IT provision, including a DHSC failure to commission and procure a national IT framework for the NHS.

In my long career in the NHS I worked with many IT systems, which increased when the 2012 Health and Social Care Act enabled independent providers to take on NHS contracts; in my case, at one point I had to use two different systems when working in an NHS setting which interfaced with a private provider of services (we had two PCs on the desk!)

· Fragmentation of the NHS due to the introduction of competitive tendering for NHS clinical services following the 2012 Health and Social Care Act, resulting in an increasing number of private commercial companies taking on NHS contracts.

Competitive tendering in itself has cost the public purse many millions of pounds extra administration and management costs. The new Bill plans to dispense with competitive tendering but independent providers will still be considered for contracts (although it is not clear on what basis this can be assessed fairly), meaning the associated costs referred to above will continue.

· Duplication of resources (such as PCs, stationery, clinical equipment), due to multiple private providers working in the same care pathways as NHS providers, has wasted precious NHS funding.

· Opening up of NHS clinical services contracts to independent providers, which take a proportion of NHS funds for profit.

In my local area (bath and NE Somerset), Virgin Care Ltd was awarded a 7 year contract to deliver community health and care services (from 2017), in preference to a consortium of NHS providers, charities and not-for-profit Community Interest Company Sirona.

The tendering process for this contract alone cost £1 million.

Virgin Care have said that they will reinvest any ‘surplus’ from their contract work back into the services but they have not so far realised any surplus in Bath and NE Somerset. It is difficult to track their financial operations as they are part of the very large Virgin Group Holdings Ltd, based in the British Virgin Islands.

Ref: Virgin Care Services: no corporation tax paid as profits from NHS contracts rise to £8m on £200m turnover (inews.co.uk)

2. NHS fragmentation

· The 42 Integrated Care Systems being set up across England, which the Bill aims to make into legal entities, represent a further fragmentation of the NHS, as each ICS will have its own ‘single pot’ budget, which it will allocate according to its own health and care needs, based on the methods of ‘Population Health Management’.

· Each ICS will be governed by an Integrated Care Board, which may include representatives of private companies, leading to further influence and integration of the private sector into the NHS and social care.

· The transfer of staff employment to the new ICS Bodies would bring a further threat to the cohesion of the NHS, as the requirement for flexible working across ICS organisations, together with only a temporary commitment from NHSE to continuity of terms and conditions when staff transfer, suggests that ICSs will be able to alter terms and conditions, as well as possibly departing from Agenda for Change pay scales (thereby dispensing with equal pay for equal work across the NHS).

· Effect on patients: I have a friend who is currently battling cancer in addition to lifelong health disabilities. She has needed to have several visits from Community Nurses, who are managed by Virgin Care in Bath and NE Somerset. Requests from the GP for blood tests (advised by hospital doctor following discharge) are hard for my friend to chase up, as she has to call the both the GP and Virgin Care in order to ensure the request has been made by the GP and to check with Virgin Care that she is on the list for the day and what time to expect the visit. This is just one small example of the fragmentation of NHS services caused by giving contracts to private providers, causing stress and anxiety to my friend who is very fatigued already from her illness and has to negotiate two phone queues just to confirm her essential care.

3. NHS privatisation

· The Health and Care Bill, if unamended (permitting private companies to join NHS Integrated Care Boards) will inevitably lead to increasing privatisation of the NHS The majority of the UK population are opposed to further encroachment of the private sector into the NHS. A survey by Survation for campaign organization We Own It last year showed that 76% of respondents wanted to see the NHS "reinstated as a fully public service, compared with just 15% who wanted to see continued involvement of private companies", echoing many other national surveys. The prospect of having private companies on NHS ICS Boards, influencing where and how public money will be spent, is anathema to the majority of UK citizens.

· Despite the fact that, under the planned re-organisation, commissioners of health and care services (the ICSs) will no longer be required to put contracts out for competitive tender, there is no guarantee that contracts will be given to NHS organisations as preferred providers, rather than to private health corporations.

· Already, Virgin Care Ltd has a place on the Bath, Swindon and Wiltshire Integrated Care System Partnership Board and the ICS leadership have not ruled out having Virgin Care (and other commercial companies) taking a place on the Integrated Care Board of the ICS NHS Body, if the Health and Care Bill passes unamended.

BSW-Partnership-Board-meeting-28-May-2021-combined-papers.pdf (bswpartnership.nhs.uk)

· There is often an assumption, with no substantive evidence to support it, that private providers of healthcare will be more efficient or cost-effective than public providers. On the contrary, there is plenty of evidence of private providers failing to deliver their contract requirements and sometimes walking away from those contracts without sanction. For example:

- in February 2014, the CQC criticised Virgin Care over its use of non-medically trained receptionists to assess patients in its Croydon Urgent Care centre. CQC inspectors found the centre was in breach of four basic standards of care.

- Circle was the private provider involved in the privatisation of Nottingham’s dermatology service, which in June 2015, was described by an independent report as "an unmitigated disaster". Once part of a national centre for excellence at Queen’s Medical Centre, it is now much reduced, with some patients sent to a centre in Leicester.

- a 10-year contract for the management of Hinchinbrooke Hospital was given to Circle in 2013 but just two years later in January 2015, Circle pulled out of the contract. The CQC found a catalogue of serious failings at the hospital that put patients in danger and delayed pain relief. The hospital was put in to special measures, the first time the CQC had had to do this.

· If the integration of private, for-profit companies into our NHS and onto NHS ICS Boards gets the go-ahead from MPs under this legislation, the potential for conflict of interests is clear, especially with the plan to drop competitive tendering for contracts – the concern about government cronyism in awarding PPE contracts looms large in this context. The award of publicly funded contracts to private companies without tender, competition or scrutiny, as has happened during the pandemic, must not be allowed to continue.

· The Health & Care Select Committee recommended in June 2019 that legislation should rule out non-statutory providers holding ICP (Integrated Care Provider) contracts in order to "allay fears that [they] provide a vehicle for extending the scope of privatisation" but this has not been referenced in the White Paper or the Bill.

Refs: Private firms given £9.2bn of NHS budget despite Hancock promise | NHS | The Guardian

NHS GP practice operator with 500,000 patients passes into hands of US health insurer | NHS | The Guardian

A snapshot of NHS outsourcing failures - NHS for Sale

NHS Long-term Plan: legislative proposals (parliament.uk) (Point 79, page 30)

4. Lack of evidence for the Integrated care System model

Finally, the Integrated Care model, as rolled out by NHSE, has not been yet provided evidence that it improves patient outcomes, hospital activity levels or achieves cost savings. In 2017 the National Audit Office said in its report :

‘The Departments have not yet established a robust evidence base to show that integration leads to better outcomes for patients’.

Ref: Health and social care integration (Summary) (nao.org.uk)

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