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

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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