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

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.

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.

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

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?

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