Workers' Weekly On-Line
Volume 51 Number 7, February 27, 2021 ARCHIVE HOME JBCENTRE SUBSCRIBE

NHS White Paper

Continuing the Wrong Direction for a System of Health and Social Care

On February 11, the Secretary of State for Health and Social Care, Matt Hancock, set out in a speech in Parliament [1] the government's White Paper on "the future of health and care", entitled "Integration and Innovation: Working together to improve health and social care for all" [2]. That the legislation is more about the future of health and care rather than "integration", "innovation" and "working together" was revealed by public health specialists Allyson Pollock and Peter Roderick in a BMJ blog post on the same day [3]. They pointed out that these proposals were "the wrong proposals at the wrong time" and "far from reversing the 2012 Health and Social Care Act, as has been widely reported", the proposals "consolidate the paradigm that the 2012 act strengthened and which the government has favoured during the Covid-19 pandemic". In other words, this paradigm is the wrong direction towards a privatised system of health and social care being rolled out on the back of the present health crisis.

Matt Hancock claimed that the legislation is about "integration within the NHS" to remove some of the "cumbersome boundaries to collaboration", although he referred not just to the NHS and local government bodies but to what he called "wider delivery partners". These, of course, are private corporations, which the government is keen to include more and more in the health and social care system.

It will also be remembered that during the pandemic the government has got used to handing out contracts worth vast sums of money to wealthy individuals and corporations without "cumbersome boundaries to collaboration". In fact, only last week a court ruled that Matt Hancock had acted unlawfully [4] when his department did not reveal details of contracts it had signed during the Covid-19 pandemic. This says a lot about the "cumbersome boundaries" that the government wants to remove in this legislation on the NHS.

Allyson Pollock, Professor of Public Health, Newcastle University

The announcement by the government followed a hurried so-called consultation by NHS England from November 26, 2020, finishing on January 8, when most people, including those in the NHS and local authorities, were focused on the coronavirus crisis. The document on which that consultation was based, "Integrated Care: next steps to build strong and effective integrated care systems across England", detailed their vision for "a more effective and responsive care system across England". Pre-empting the White Paper, and without any legislation in place, they stated: "This document sets out how NHS organisations, local councils, front-line professionals and others [our emphasis] will join forces in an integrated care system (ICS) in every part of England from April 2021." Actually, the ICS, for example, is already up and running in the north east and Cumbria with the Chief Executive and Board members appointed, even without statutory powers to commission services.

This direction outlined now in the White Paper will abolish local Clinical Commissioning Groups (CCGs) and set up regional Integrated Care Systems (ICSs) as part of the "long term NHS plan" and allegedly learning the "lessons of the pandemic". This is intended to become law in April 2022. This would give much more power for corporate decisions to be made away from local areas in favour of private consultancies and health corporations, at a time when the government has been drastically cutting the budgets of NHS Trusts over many years. This has led to forced financial mergers, the closure of hospital beds en masse at local hospital acute and mental health services, as well as losses of community services. It has also been a deliberate path of continuing to force the NHS to contract out ever more services to private hospitals at huge financial cost.

The White Paper says that "we will put pragmatism at the heart of the system," claiming they are "Enabling the NHS and local authorities to arrange healthcare services to meet current and future challenges by ensuring that public and taxpayer value - and joined up care - are first and foremost." This will require "changes to both competition law as it was applied to the NHS in the Health and Social Care Act 2012 and the system of procurement applied to the NHS by that legislation" (our emphasis).

Peter Roderick, Principal research associate, Newcastle University

It should be said that to put pragmatism at the heart of the system is to put the same corrupt decisions supposedly aimed at "getting things done" in business and public affairs that the government has been using over the pandemic, decisions that serve private interests and are not based on public authority and the necessity to keep our health and other services publicly provided and accountable to the communities and people they serve in the short and long term.

Speaking about the competition law and system of procurement, Pollock and Roderick point out: "The core elements of the disastrous Lansley reforms remain in place: no duty on the government to provide key services throughout England to everybody; entitlement to services dependent on membership, now of clinical commissioning groups (CCGs), in the future of 'Integrated Care System (ICS) NHS bodies,' though abolition of CCGs is implied, not expressed; commercial contracts and the purchaser-provider split still the basis for delivering services; foundation trusts still able to receive 49% of their income from outside the NHS; and public health functions and communicable disease control remain outside the NHS." They point out: "Decisions on reconfiguration and funding will be provider driven and at scale, implementing 'proposals developed by clinical and operational networks' rather than based on the needs of local communities. This market paradigm is very different from area-based auth orities with responsibility for planning, and administering local services to meet local needs. Integrated Care Systems will be able 'to delegate significantly to place level and to provider collaboratives,' including the use of 'fully-fledged integrated care provider [ICP] contractual models.' Place levels are not defined. Provider collaboratives are not defined either, but are self-determined, with no required local connection and clearly open to multinational private companies and monopoly power."

The authors say that, according to NHS England, "A statutory 'ICS NHS body' ... will receive a 'single pot budget' which will merge the budgets for general practice with acute and other services. It will 'take on' the CCG and some NHS England commissioning functions. Its board will include representatives of NHS trusts, local authorities and general practice 'and others determined locally.' General practices taken over by US corporations would be included. No controls are proposed over whom the other board members may be. They could therefore include, for example, private hospital groups, nursing home chains and the 67 companies awarded a £10 billion contract last November for NHS inpatient, day case, pathology and imaging services, urgent elective care, cancer treatment, and diagnostic services."

The White Paper is also almost silent on how the alignment of health and social care services and funding of health and social care will take place. In the 1990s, the Conservative and Labour governments respectively separated and continued the separation of the funding between "health" care and "social" care. It introduced charges and "means testing" for "social" care. This one measure was used to privatise the elderly care-home sector and social care and the closure of NHS elderly care wards and hospitals. The White Paper's only reference to this is that the government will "also bring forward changes in social care, public health and mental health" and that the government also remains "committed to the sustainable improvement of adult social care" and will "bring forward proposals this year".

Whilst the White Paper remains vague on so many of these vital questions in maintaining a universal system of health and social care, it is very clear on the powers of the government to intervene in the NHS for those interests it represents. The White Paper says that the legislation "will merge NHS England and NHS Improvement", it will be placed on a "statutory footing" and will be designated as "NHS England". This will be complemented by "enhanced powers of direction for the government" over the newly merged body.

Whereas the Health and Social Care Act of 2012 had legislated to remove the explicit duty of the Secretary of State for Health and Social Care to provide a comprehensive health service and instead only "promote" this service, the White Paper proposes this duty be restored in that "the Secretary of State will be empowered to set the direction for the NHS and intervene where necessary". It is clear what this direction is! And the Health Secretary will be responsible, but unaccountable for their irresponsibility! The government expects that the new legislation will be designed as a new model of handing out contracts to the private sector without any "cumbersome" regulatory systems of procurement and market bureaucracy. This is the model that they now want and, though the game is the same as it was before, now the government wants to be more hands-on in handing out the contracts.

This is an all-round wrong direction towards a privatised system of health and social care being rolled out on the back of the present health crisis. What is needed is a new direction where public authorities based on health staff and on people in the communities they serve are empowered to directly speak about their needs and participate in making the decisions. A human-centred system providing a universal and publicly provided health and social care system at the highest level which is free to all is the requirement of the times.


1. "The future of health and care", Matt Hancock, Oral Statement to Parliament, February 11, 2021
2. "Integration and Innovation: Working together to improve health and social care for all", Policy Paper, February 11, 2021
3. "A new bill to reform the NHS in England: the wrong proposals at the wrong time", Peter Roderick, principal research associate, Newcastle University, and Allyson M. Pollock, professor of public health, Newcastle University, February 11, 2021
4. In his ruling, Mr Justice Chamberlain said: "There is now no dispute that, in a substantial number of cases, the secretary of state breached his legal obligation to publish contract award notices within 30 days of the award of contracts."


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