Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by commissioning correspondent, Sharon Brennan.
NHS England has at last published a response to the consultation on its integrated care provider contract, and what stands out is how unappealing it has made it for private companies to want to get involved with this project.
To understand why, let’s recall how the project got to this point: NHS England originally published a ICP draft contract in 2017 - itself a culmination of several years’ thought - back when they were due to be called “accountable care organisations”. The work has since seen much delay, involving much political controversy, two judicial reviews to the contract, and a Commons health committee inquiry.
An announcement by NHS England in January 2018 that it would launch a consultation on the contract was in part a way to head off concerns that ACOs, now ICPs, were about backdoor privatisation.
The legal challenges have been lost, the health committee recommended going forward with some substantial amendments and provisos, and the consultation itself was eventually launched in August.
It is hard not to read NHS England’s consultation response as a statement from an organisation exasperated that the privatisation myth still percolates.
The document emphasises that to all intents and purposes ICP contract holders will have to act like a statutory body - even if they are not.
The new contract is designed to allow commissioners to procure general practice, wider NHS services and some local authority services through a single contract let to a lead provider.
Following the consultation, it now demands two key things from any would be ICP provider: financial safeguards that are over and above those in the standard NHS contract, and clear public transparency.
ICP providers will be forced to maintain a minimum level of assets. Clinical commissioning groups will have the power to strip away parts of the contract if quality and financial conditions are not met, and CCGs will be able to work directly with ICP sub-contractors if needed.
The contract mandates ICP providers to hold public board meetings, work with Healthwatch, and publish performance and financial information - these could be fascinating and powerful precedents to set for other private providers of NHS services in future (I would add, importantly, that they should be given duties under the Freedom of Information Act - something GP practices already have).
Paul Maubach, accountable officer of Dudley CCG, the first commissioner in line to use the contract, welcomed the changes.
He told HSJ that if the contract was about organising health provision on the basis of population health, “why wouldn’t you want more public accountability and engagement about the kind of care that needs to be provided?”
NHS England has already made very clear that statutory public providers are highly likely to be the “most capable organisation” - or indeed the only capable organisations - to hold these ICP contracts.
But it is hampered by current procurement laws - both NHS specific rules and wider ones - from ruling out independent sector providers altogether.
NHS England has proposed legislative changes which could change this - allowing the NHS to be exempt from some competition rules, and to create statutory integrated care trusts which would be designed to run these kinds of arrangements.
But officials don’t want to wait until 2022, the very earliest legal changes could come into play, to change the way the NHS operates.
In the meantime, setting such stringent rules on ICP providers, requiring them to act in many ways like a public sector body, almost certainly means none will bid for any ICP contract (they would not want to face such scrutiny) or, if they do, won’t win it.
As such the contract is a bridge between the current legal framework and any future changes to the law.
It signals one way NHS England intends to push closer integration despite the Lansley Act putting competition over co-operation.
The big question, however, is whether the ICP contract will be at all popular - and adopted - by the service. Dudley is currently the only CCG clear that it wants to commission one. The City of Manchester has decided, after initial interest, to first see how Dudley gets on with using the contract.
Dudley is hoping to have procured and implemented an ICP contract by April 2020 but, after years of delay so far, it would be no surprise if this complex project was pushed back further.
As for elsewhere, NHS England said contracts will be adopted in a “controlled and incremental way”. It said it expects “further iterations” of the contract may be published to iron out issues which arise once it is used in practice. Take from that what you will.
NHS England consultation response to ICP contract, HSJ interviews
March, April 2019