Integrated Care Regulations

I beg to move,

That an humble Address be presented to Her Majesty, praying that the Amendments Relating to the Provision of Integrated Care Regulations 2019 (S.I. 2019, No. 248), dated 13 February 2019, a copy of which was laid before this House on 13 February, be annulled.

I am grateful that we have found time to debate this prayer motion in my name and the name of my right hon. Friend the Leader of the Opposition. For the Government to have attempted to make these changes without proper scrutiny is a huge discourtesy to the House. These changes are fundamental, with potentially far-reaching implications for the NHS, and they have aroused concern—[Interruption.]

Order. It is not fair to the hon. Gentleman that people who have voted are now having conversations here. I would be grateful if people who wanted to talk about other things left the Chamber.

The changes in the regulations have aroused considerable concern in the country, and proper parliamentary time should have been made available for a proper debate on them; they should not have been made through secondary legislation.

The Opposition oppose the regulations and will seek to test the House’s opinion on them. We oppose the changes not because we are against integration. We have long called for greater integration of services to offer seamless care to patients, because the demands on the NHS are of a different nature from those of 71 years ago, when a Labour Government created the NHS with a tripartite structure. In those days, life expectancy was so much shorter, and infectious disease was the overwhelming medical challenge. In 2019, we are worlds away from the days when 30,000 hospital beds were set aside for the treatment of tuberculosis, or when wards were filled with row after row of iron lungs to treat those suffering from polio. Today, we are all living longer, with a variety of complex conditions, from diabetes to cardiovascular disease and chronic obstructive pulmonary disease—conditions that increase the risk of a poorer quality of life and mean a greater risk of premature death. Indeed, around 14.2 million people in England—nearly a quarter of all adults—have two or more conditions. More than half of hospital admissions and out-patient visits, and three quarters of primary care prescriptions, are for people living with two or more conditions.

The issue is not just ageing and frailty; poverty takes its toll. People in the most deprived areas of England can expect to have two or more health conditions at 61 years—10 years earlier than people in the least deprived areas. Health inequalities are widening, while advances in life expectancy are stalling. An ageing population, the increase in long-term conditions, and the increasing number of people with multiple health conditions means that we need to integrate services. Sometimes in these debates, when we talk of long-term conditions, we suggest that we are talking about a homo- geneous group, but it is quite the opposite. We could be talking of a 61-year-old man with renal failure and high blood pressure, or a 101-year-old woman with profound deafness and blindness. The way that such conditions affect quality of life, and the extent to which they are amenable to medical intervention, is likely to vary.

If health services are not better co-ordinated and not integrated, there is a greater risk to patient care through the poor co-ordination of medical care and increased time spent managing illness. The need to manage multiple medications may lead to poorer medication adherence, adverse drug events, and the aggravation of one condition by the symptoms or treatment of another. It can also mean damaging self-management regimes in which there are competing priorities, and a bewildering landscape for patients, who are often of an advanced age, with cognitive impairment and limited health literacy, so we support integration.

Very quickly, does my hon. Friend not agree that the big problem with integration, if we support it, is the lack of funding, and the lack of proper training in the various disciplines? Only a couple of years ago, there was a cut in the funding for pharmaceuticals.

My hon. Friend makes a very important point. Integration is not about saving money. For integration to work properly, it needs to be fully funded, and, of course, the NHS has been through the biggest financial squeeze in its history. We do not oppose integration. Indeed, that is why the previous Labour Government introduced a section 75 partnership arrangement, and why we were so vociferous in our opposition to the Andrew Lansley Health and Social Care Act 2012, which went completely counter to international evidence and exacerbated local fragmentation of health structures. It is a delicious irony that Ministers, all of whom were dragooned through the Lobby to support the Lansley Act, despite expert after expert warning them what a mistake it would be to press ahead with it, are now trying to propose regulatory changes, so that we can essentially work around that Act. The reason why we cannot support the regulations today is that the most damaging part of that Act is still on the statute book.

On the point about the Health and Social Care Act, a third of the contracts have been awarded to private providers, and millions were wasted when they collapsed. The explanatory memo for this statutory instrument says that it is expected that organisations holding an integrated care provider contract will be statutory providers, such as NHS foundation trusts, but that is not legally binding. To protect our NHS, do we not need to know definitively that providers will be public, not private?

My hon. Friend is absolutely right. Of course, the Minister cannot give that reassurance because of the Lansley Act that Ministers voted for in 2011.

I am only sorry that I cannot be with my hon. Friend on the Front Bench tonight. I have really enjoyed working with him; he is a fine shadow Secretary of State, and I know that he will make an excellent Secretary of State. Unfortunately, I cannot be with him, because when we on these Benches vote against the Whip, we have to deal with the consequences.

As my hon. Friend knows from many debates I have taken part in for the Opposition, despite repeated questions to various Ministers, there has been no absolutely no reassurance that the private sector will not continue to be involved in these matters.

My hon. Friend makes his point typically eloquently and with force. May I say to him that we miss him on the Labour Front Bench? He was a real rock in the shadow Health and Social Care team. It is typical of him that when he decided last week that he could not support the Labour Front Bench position on a referendum, he took the honourable course of action and chose to leave the Front-Bench team. I think that he has the respect of many in the House for that position.

This is the nub of our opposition tonight. Contracts are still being put out to competitive tender, even when some commissioners claim that they do not wish to do this. Here lies the danger: nothing prevents, and some things might encourage, these integrated care partnership contracts being put out to tender and perhaps being won by a private sector provider. Ministers repeatedly tell us that ICPs, and before them accountable care organisations, are not about ushering in a further role for the private sector. If that is the case, and if patients and staff are to have confidence that the ICP contracts will not end up in private hands, the Government’s overarching competition legislation must be changed first. As that legislation has not been changed, and as we will still have commercial contracting for the delivery of medical services, there is a risk that a multi-billion pound contract covering hundreds of thousands of people and packaged up for 10 to 15 years could be handed over to a big provider. That is why the Health Committee, which is broadly supportive of these integrated care models, issued this warning in its report:

“The ACO model”—

it was using the terminology of the time—

“will entail a single organisation holding a 10–15 year contract for the health and care of a large population. Given the risks that would follow any collapse of a private organisation holding such a contract and the public’s preference for the principle of a public ownership model of the NHS, we recommend that ACOs, if introduced, should be NHS bodies and established in primary legislation.”

We agree.

The impetus for this contract comes from the example of Dudley, which I am sure the Minister will want to talk about. When the chief executive of Dudley CCG attended the Select Committee, even he conceded—although he said that it was unlikely—that because of the procurement rules, it would not have been possible to have kept out private providers applying for the contract. When asked whether the contract could go to a private provider, he said:

“In theory, it is technically possible for that to happen”.

Does my hon. Friend agree that to cure these problems, we need not secondary legislation, but a thoroughgoing review of NHS legislation?

My hon. Friend is right; we need to sweep away the Lansley legislation and put the NHS on a sustainable public footing. NHS England attempts to reassure those who are concerned about this contract by putting in place some further conditions. It talks about transparency and insisting on a “minimum level of assets”. Note the qualifier “minimum”—not all assets. It also talks of a

“restriction on carrying out any business other than that required by the ICP Contract”.

Again, note the words used—not a prohibition on other business activities, just a restriction. This is in the circumstance when the contract is awarded to a non-statutory provider.

NHS commissioners are obliged by law to advertise many larger NHS contracts, giving firms such as Virgin Care the chance to bid. Since the Lansley Act came in, £10 billion of contracts have gone to private providers, and there is a further £128 million of NHS tenders in the pipeline. It is all very well for the Secretary of State to go to the Health and Social Care Committee as he did a few weeks ago and say:

“There is no privatisation of the NHS on my watch, and the integrated care contracts will go to public sector bodies to deliver the NHS in public hands.”

The Secretary of State is not in a position to make that promise to the Committee, because of the legislation that is in place.

As my Committee has already been quoted, I think that it might assist the House if I were also to quote from the conclusions that we came to on this issue. The Committee said:

“We recognise the concern expressed by those who worry that ACOs could be taken over by private companies managing a very large budget, but we heard a clear message that this is unlikely to happen in practice. Rather than leading to increasing privatisation and charges for healthcare, we heard that using an ACO contract to form large integrated care organisations would be more likely to lead to less competition and a diminution of the internal market and private sector involvement.”

The hon. Lady makes an interesting point. She is correct in as much as there is not currently a long queue of companies lining up to take control of whole health systems, but that could change if some new form of Transatlantic Trade and Investment Partnership is brought in by a post-Brexit deal. A number of these companies are becoming increasingly litigious in the courts, which is why Virgin Care took the NHS in Surrey to court. However, even if a private provider is not gifted a whole contract, which is the point that the hon. Lady is making, there is nothing to prevent it from buddying up with NHS bodies in joint ventures as a way of exercising influence over the way in which local health systems are configured. There is already evidence of private sector involvement in the establishment of the integrated care system, with Centene UK—an offshoot of an American health insurer—working with Capita in the Nottingham ICS.

Earlier in his remarks, my hon. Friend talked about confidence for people locally in what is happening in the NHS. Further to the point made by the hon. Member for Totnes (Dr Wollaston), only in February NHS England itself issued its case for primary legislative changes in which it says, with regard to these proposals, that it wants to

“start a broad process of engagement with the NHS, its partner organisations and those with an interest in how our health service operates.”

That will hopefully involve patients and the public. In Bristol, we embarked on a 10-year contract for community services on the day after the NHS plan was invoked without consultation with local people, an assessment of basic health needs or alignment with the rest of the situation. The problem is that we have yet another change that people locally do not have confidence in. It really is time for the Government to come forward with a cohesive change for the future.

That is absolutely right. Notwithstanding the sincere views of the Select Committee, there is a lack of confidence out in the country about the way in which these commercial contracting arrangements work. We are seeing that in Bristol, as my hon. Friend so eloquently outlined. Despite the blasé attitude of the Secretary of State in the Select Committee, this is the same Secretary of State who has sat back and done nothing while a PET-CT cancer scanning contract in Oxford is privatised, leading to a fragmented service putting patient safety at risk.

I know my hon. Friend has been working very hard on this issue. I have had droves of patients and staff contacting me with their concern about what is happening. They are astonished that this privatisation is continuing given the comments made by the Secretary of State. There seems to be no willingness at all for any challenge to NHS England’s decision, which is going above the heads of those who deliver the care and which, as my hon. Friend says, would threaten its quality and safety.

We keep being told by Ministers, by those who are favour of integrated care and by various interested stakeholders that Labour Members are scaremongering and that we have nothing to worry about—that it is all going to be fine and all going to be in the public sector—yet at the same time we are seeing controversial privatisation after privatisation all across the country, of which the one in Oxford is just the latest example. This has happened since the Secretary of State went to the Select Committee and said that there would be no privatisation on his watch.

In south-east London, private companies are in a three-way fight for the biggest-ever NHS pathology contract—a £2.2 billion contract for 10 years. If the Secretary of State was sincere in his commitment to no privatisation on his watch, he would bring forward legislation to ensure that ICPs are statutory public bodies that are publicly accountable. He would first take the advice of the NHS itself, as embodied in the long-term plan and the subsequent proposals for legislative change, and rid our NHS of the morass of competition law and economic regulation that was brought in by the Health and Social Care Act 2012. Everyone agrees that this particular aberration has had its time.

While the NHS proposals do not yet go as far as Labour Members would want and would not resolve all the problems of the internal market and private sector involvement that our NHS struggles with, they would remove the default assumption for competitive tendering that would currently make many ICSs feel obliged to put contracts for ICPs out to tender for fear of falling foul of the competition rules. Overall, they provide a far preferable base from which to pursue integrated care than the maze of contradictions and obstacles that Andrew Lansley’s Act forced on them. Rather than this regulated change, why is the Minister not bringing forward the legislation that NHS England has called for?

I have two other quick points for the Minister. The new secondary legislation seeks to substantially change the regulations underpinning the existing contractual arrangements for the provision of NHS GP services. We should remember that general practice is already hard to recruit for and we are already losing GP numbers, yet the proposal to incorporate GP practices into ICPs appears to cut across the idea of GPs beginning to work in wider networks covering 30,000 to 50,000 patients, retaining their GP contracts but sharing common resources. That was highlighted as a direction of travel to be celebrated by the Prime Minister when launching the long-term plan.

GP practices can already network and collaborate without this new contract. The contract will offer a sweetener to GPs of new money if a GP practice signs up to the new contract, but the proposals have been opposed by the BMA. Dr Richard Vautrey has said:

The hon. Gentleman talked about the funding of social care. One of the recommendations made by the Health and Social Care Committee, in concert with the Housing, Communities and Local Government Committee, as a solution to adult social care funding, was a system of social insurance. Would he support that on a cross-party basis?