NHS England should work with local leaders and clinicians to explain accountable care

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Claims that the growing interest in accountable care organisations and systems is undermining the NHS are ill founded at best and misleading at worst. These claims are at the heart of two legal challenges to NHS England’s draft contract for accountable care organisations. The contract has been presented by the government’s critics – who include Stephen Hawking, the theoretical physicist and author – as opening the door to greater private sector involvement in the NHS. For the reasons set out below, this seems highly unlikely.

I know because I’ve had the opportunity to see for myself what is happening in areas of England putting in place accountable care organisations and systems. From Cornwall to Cumbria and from Blackpool to Bury St Edmunds, NHS leaders and their local government counterparts are working in partnership to improve health for the populations they serve. Much of this work is happening from within the NHS, rather than in response to government policy, as local leaders and clinicians see opportunities to meet the needs of patients and local populations more effectively.

Take Greater Manchester as an example. Under its devolution deal with the government, the health and social care partnership is supporting the city of Manchester and the nine other areas that together make up Greater Manchester to put in place integrated systems that join up care provided by the NHS, local authorities and the third sector. Strengthening mental health services and joining up community services are high priorities, as is work to tackle the social and economic determinants of health through collaboration with other sectors.

A different example is the Frimley Health and Care System in Surrey, Hampshire and Berkshire, one of the eight accountable care systems in England. Here the focus is on developing joined-up care in the community that connects general practices with other services and builds stronger links between physical and mental health services. This work is helping to moderate demand on local hospitals by providing better access to GPs and alternatives to hospital care.

For critics to interpret these developments as a move towards privatisation is perverse. In reality, it marks a further shift away from the marketisation of the NHS that many of these same critics fought against in the debate on Andrew Lansley’s Health and Social Care Act. How then have the government and its critics come into conflict about these developments?

Two factors are important. The first is the use of terms such as accountable care organisations and accountable care systems to describe what is going on. These terms originate in the United States and have connotations of the inequities and excesses that are evident in that country’s health care system. By extension, critics of the current direction of health policy in England argue that the NHS is being prepared for takeover by US corporations motivated by profits rather than health improvement. This is understandable but misguided.

The second is that the draft contract for accountable care organisations has acted as a lightning rod for those opposed to accountable care. The contract aims to provide advice and guidance to areas planning to procure integrated care models and the government is consulting on changes to regulations to enable its implementation. It is important to note that the contract is not currently in use and is likely to be invoked sparingly when it does become available because of its complexities. NHS organisations are exploring other ways of integrating care thereby avoiding the drawbacks of the proposed contract.

An informed and measured debate about these issues would start by acknowledging that language matters. Lewis Carroll famously reminded us that words mean many different things and in health policy their misuse can be inflammatory. Recognising that what the NHS calls accountable care organisations are actually integrated care partnerships of health and social care providers, and accountable care systems are collaborative care systems created to plan for the future, would be both helpful and accurate. These models are developing without the need for procurement and do not require a new contract to be in place for them to progress.

There also needs to be greater understanding of what is happening in different parts of the country. Developments at a local level make it clear to anyone who cares to look that private sector involvement is extremely limited and tends to be focused on back-office support rather than the delivery of clinical care. Responsibility for service provision lies mainly with the public sector and there is no evidence that private corporations have much appetite to take on care currently delivered directly by the NHS. Why would they when funding is so tight and profits hard to come by?

The best way of assuaging the fears that exist would be to encourage greater transparency about these developments. Misunderstanding is fuelled by worries that plans are being created behind closed doors, as happened in the work that went into sustainability and transformation plans. NHS England should lead the way in explaining why it is encouraging these developments with the support of local leaders and clinicians who have been instrumental in work done to date. The disinfectant of sunlight is much needed.

The bold aim of making ‘the biggest move to integrated care of any major western country‘ is to be welcomed and supporters of the NHS should put their weight behind this vision. 

Comments

David Kirby

Position
General Medical Practitioner,
Organisation
HackneY Keep Our NHS Public
Comment date
18 December 2017

This patronising attack on those who see in Jeremy Hunt's attempts to introduce Accountable Care Organisations into the NHS as a further step towards commodification of health care, and towards the dismal standards of the US organisations that it is based on reveals a faux naivety that clearly has a political basis. If there is really such a misunderstanding of Hunt's intentions, he could quite easily clear them up by stating that Accountable Care Organisations will be prevented by law from diverting any funds from taxpayers, paid for the purpose of implementing a fair and accessible system of health and social care for all, into profit for private owners of capital whether that is used for buildings, or for providing services. Everyone knows that the US based multinationals involved in the ludicrously wasteful and inefficient system in that country are seeking to expand abroad, and that they have massive funds available for lobbying - perhaps they contribute to the Kings Fund?

Maurice neville

Position
Councillor,
Organisation
Borough council
Comment date
18 December 2017

Chris Ham is caricaturing the opposition to ACOs for some reason best known to himself. There is,despite his blanket denial,ample evidence of a desire by corporations to take over NHS services at front line ...he appears to be unaware of Virgin Care for example. The heavy involvement of 'consultancies' from the private sector in being paid to create ACO and ACS structures is clearly a very good way for the private sector to expand its in depth knowledge of the NHS. Presumably he thinks the slavering tidal wave of articles in the right wing press, from think tanks and from Tory politicians which declare the NHS unviable are nothing to do with real life? Social Care has already been disfigured by mass privatisation of care homes with disastrous consequences .. does he expect us to believe that the hedge funds and other vulture capitalist entities don't have their eyes on healthcare? The evident admiration from the Kings Fund for ACO type systems in the USA, Europe and elsewhere tends to skate over the private sector aspect. There is as he well knows no presumption that an ACO contract be held within the public sector and nothing to stop a large scale takeover of an ACO by a company. He entirely ignores the fact that opposition to ACO systems is also based on the way they are being proposed in an obviously dishonest way as a solution to underfunding. This is a superficial and misleading piece unworthy of the Kings Fund

Jacky Davis

Position
NHS doctor,
Organisation
NHS
Comment date
19 December 2017

There is an easy way to allay concerns about the private sector taking over ACOs. The government just needs to get rid of the NHS market in England. Until they do there remains the possibility that entire ACOs will be run by private companies. It's no good saying that that is not happening at the moment, as long as it is a distinct possibility in the future.

We see large contracts still going to Virgin, who recently successfully sued the NHS for a reported £2 million plus over a lost contract. No wonder people are nervous about plans which further lay the NHS open to such companies.

The NHS market in a England has been a failure, everyone including parliament knows it. Time for the Kings Fund to call for an end to it.

Kevin Donovan

Position
Retired,
Organisation
Defend Our NHS
Comment date
19 December 2017

Oh, really! Why make excuses? It is clear from the ideological motivation and the policy and practice changes involved that the whole STP/ACO/ACS nightmare is intended to undermine a national health service and replace it by a fully marketised system. We expect excuses from some but the particular current disgrace is the failure by so many MPs and local councils to see what is happening and put a stop to the whole sorry business.

Jenny Shepherd

Position
Chair,
Organisation
Calderdale & Kirklees 999 Call for the NHS
Comment date
19 December 2017

Suzanne Kelsey

Position
Retired lecturer in health and humanities,
Organisation
NHS campaigner
Comment date
19 December 2017

I am no medical expert but I am a dedicated NHS campaigner both locally and nationally and agree with all the comments on here.

It seems obvious that the NHS is being made to fail, with humanitarian crisis after crisis with needless and very costly radical reforms alongside ‘efficiency savings’ which means vital facilities closing down. This causes great anxiety to patients and their families especially those who have to travel great distances in rural areas with inferior transport links..

Even today we are reading about the worrying shortage of front line staff. The very expensive outsourcing of services with the subsequent fragmentation is proving a complete disaster.

You only need to walk into the emergency department of most hospitals to see the evidence of that. Or speak to patients who are suffering because they have had their elective surgery cancelled time and time again. Or speak to exhausted frontline staff who are understandably very concerned about patient safety and their own well being.

I also know that ACOs are an American export and we are all aware of the appalling health care system in America where you get sent home to die if you cannot afford expensive treatment.

Chris Ham acknowledges that our concern is understandable but misguided and also asks for transparency whilst others need much more scrutiny and serious debate. I do believe none of the electorate voted for any of this. In fact we were promised there would be no top down reorganisation of our NHS and it was safe in their hands.

Perhaps he would like to guide us into enlightenment then and explain the continued and escalating crisis in our NHS, the lack of beds whilst community hospitals so vital to isolated areas are being closed, the billions it is costing to outsource to private companies, where profit will be a priority, the increasing number of private GP services being established that will further remove funding from already struggling GPs, as they are left with the more expensive complex health issues. And why so many desperate patients are turning to private health care, leaving those of us who cannot afford it or even get it because of chronic illnesses, with a sadly depleted NHS teetering on the edge of an abyss, which is how many fearful patients feel.

ian brown

Position
carer,
Comment date
19 December 2017

"Developments at a local level make it clear to anyone who cares to look that private sector involvement is extremely limited and tends to be focused on back-office support rather than the delivery of clinical care. " Really? When Branson's Virgincare has over a billion £'s worth of contracts in clinical care (all community nhs care in north kent and other parts of the country,and he sues the NHS when he is denied a contract, plus Care UK getting contracts NOT back office and these 2 firms pay no tax in UK. Methinks you talk doublespeak.

Nigel May

Position
Member of Citizens Advisory Panel,
Organisation
NHS Kernow
Comment date
21 December 2017

The article states that those who “ argue that the NHS is being prepared for takeover by US corporations are misguided”. From current evidence it would seem we are correct in our opinions, the increasing presence of Virgin and others in directly delivering health care. We have seen several companies in Cornwall SERCO, Ramsay Health - care pull out from operating services leaving the local NHS to pick up the pieces.
With ACOs bringing together a much larger range of services and the consequent budget then they will become increasingly attractive to the private sector ( One surmises that the bigger the operation the less likely it will be allowed to fail – cf Banks and so the tax payer will always have to be in the background)
The current government has shown no indication that the expansion of the private sector in the NHs is not going to continue to grow, in fact we see the quite the opposite.
In communication with Canterbury Health Board who have been operating an ACO for 10 years they state that to make such an organisation work there needs to be trust and transparency.
For those who work with and for the NHS, we have lost complete trust in the Department of Health and the current Government to ensure that the NHS (and Social Care) is developed in a way to provide a safe and effective health and social care service for the 21st century. The bringing in of ACOs , out of the blue, over and on top of the developing STPs , does not indicate any interest in transparency.
There is no-one who disagrees with the principles of bringing together both health and social care so the current distrust caused by this ( and the previous) government’s approach to health and social care has made such a development extremely difficult and contentious.

Chris Ham

Position
CEO,
Organisation
The King's Fund
Comment date
21 December 2017

Thank you to those who've commented on my blog. Here are a few responses.

The King's Fund has been at the forefront of debate about the impact of austerity on the NHS and social care and the impact of financial pressures on patients and staff. We have also made the case, based on evidence, for additional funding to sustain services and standards, most recently in our joint submission with the Health Foundation and the Nuffield Trust to the Chancellor ahead of the budget. Our reports on these and other issues can be accessed on our website.

The private sector has always played a part in providing NHS funded services and its role has increased under successive governments. Despite this, most NHS care is delivered by NHS organisations. There is good and bad performance in the NHS and the private sector, and both have a part to play provided that acceptable standards of care are delivered.

The review we carried out of the impact of competition, regulation and performance management in our report, Reforming the NHS from Within, concluded that markets had not had the effect that some politicians had hoped for. We went on to argue that much more effort should be placed on supporting staff and local leaders to improve care by equipping them with the skills to do so rather than using external pressures. There are some good examples of this happening in the NHS and we need many more.

Our recent work has put the case for much greater integration of care, both within the NHS and with social care and other services, rather than competition. This is beginning to happen in the new care models set up under the five year forward view and in the various versions of accountable care that are emerging. It's early days but for those of us who've been advocating integrated care, it's heartening to see collaboration trump competition. The Canterbury Health System in NZ, mentioned by Nigel in his post, is an example of the benefits of this way of working in a publicly funded health care system.

I wholeheartedly support the call for transparency and debate about what's happening, hence the comment in my blog on the 'disinfectant of sunlight'. The clinicians and managers leading this work in the NHS have nothing to hide and much to be proud of. STPs have got a bad name because of lack of transparency even though they are the right thing to do, a mistake that should not be repeated.

Private sector involvement in the new care models that I've visited - other than those led by GPs who of course are and always have been independent contractors - is confined to providing back office support to the NHS. Private companies like Virgin are delivering clinical services but this has been happening for some time and is not the result of recent developments in accountable care.

I don't expect the proposed contract for ACOs to be used other than in a small number of cases. The most advanced examples of integrated/accountable care see no need for such a contract as they are led by NHS organisations - often with local authority involvement too. I fully expect this to continue.

Mr R W Ebley

Position
Retired,
Comment date
23 December 2017

In order that change is effectively undertaken all levels of government and other public funded organisations need to demonstrate good management

Independent management accreditation is required to achieve this

Thank you

Robert Charlesworth

Position
Branch Secretary Unite Community Cumbria,
Organisation
Unite Community
Comment date
29 December 2017

I wonder if the proponents or supporters of ACOs also realise that they have largely failed in their stated aim in the USA of reducing rising healthcare costs (which is inevitable when you understand how inefficient healthcare markets are, and how some companies are literally making a killing). With ACOs we will have the worst of both worlds: wasted public money and rationed care. Our healthcare system will be neither efficient not equitable. The amount of mis-information and naivety around this issue from those who should know better is a disgrace.

Robert Charlesworth

Position
Branch Secretary Unite Community Cumbria,
Organisation
Unite Community, Cumbria Health Campaigns Together
Comment date
29 December 2017

Entirely agree Kevin. Most of our elected representatives have be negligent in scrutinising the changes, from MPs in committees and on the back benches of parliament, to local councillors on Health Scrutiny Committees. The biggest changes to healthcare provision in 70 years are largely going through on a nod and a wink, and if it wasn't for the tireless and diligent work of campaigners, poring over official documents, campaigning for months on end to save their local A&E or care services, and organising regular public events and press releases, we would know next to nothing about it.

sara wilmington

Position
Deputy Head Children & Families,
Organisation
NHS
Comment date
20 February 2018

interested in yr comments

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