Three core elements
In the case of the NHS, ACOs and ACSs (terms often used interchangeably to describe very similar set ups) can be thought of as comprising three core elements.
First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.
Variations on these core elements centre on the involvement of general practitioners in the network of providers delivering care and of local authorities as providers and commissioners of services.
The most ambitious plans for ACOs in England extend well beyond health and social care services to encompass public health and other services. In Greater Manchester, for example, the aim is to use all public resources to improve health care while also tackling the wider determinants of health. This work, and that of other STPs, points to the emergence of what we have called population health systems, which seek to integrate care and to improve the broader health and wellbeing of the local population.
There is no single model for an ACO and so local context is important in shaping the approach taken in different areas. In some places, it is likely that working towards integrating hospital, community, mental health and adult social care services will make sense, whereas in others there will be an appetite for more broadly based partnerships. Elsewhere, horizontal integration, such as hospital chains and groups, may be the focus. There is no evidence that one form of ACO is superior to others and much depends on developing the leadership and collaborative cultures required to improve care.
Every ACO needs to adapt to the history of local collaboration and the willingness of partner organisations to find common cause. Progress is likely to be made more quickly in areas where organisational arrangements are relatively simple and more slowly where they are complex. Areas in which organisations are performing well often have a head start on areas where organisations face challenges, although a ‘burning platform’ can also serve as a stimulus to action.
What do ACOs do?
Delivering high-quality care in the community and people’s homes is a priority for ACOs in the United States – as it is for emerging ACOs in England. This means understanding the population served and stratifying that population according to need and health risk. People at high risk of hospital admission may receive support from case managers and others to help them live at home. People with long-term conditions will often receive targeted support to help them manage their health. Others will be helped to remain in good health through screening, and the provision of advice and other forms of support.
Many ACOs in the United States are focusing on improving access to primary care services and drawing on the range of skills and resources available outside hospitals – including community nurses, social workers and other staff. They are also putting in place new roles and processes to co-ordinate care across the health and care system. As well as improving care for patients, a common aim is to reduce unnecessary hospital use and associated costs by anticipating the needs of patients before they experience a crisis.
Within hospitals the aim is to avoid admission by assessing patients in A&E and providing care in the community where appropriate. For patients who are admitted, medical specialists known as hospitalists manage care with support from other clinicians and discharge planners to minimise lengths of stay. After discharge, patients are followed up by phone or in their homes to ensure continuity. Skilled nursing facilities may be used for patients who are not ready to go home. Some ACOs are also starting to address the social needs of their patients, such as housing, income support and access to legal services.
The most advanced ACOs use electronic patient care records so information about patients is available wherever they receive care. Information technology enables patients to communicate with doctors and nurses through email and other means, while enabling ACOs to communicate test results, and provide reminders of appointments and screening opportunities. ACOs can also use patient information for population health management (for example, by segmenting the population based on health needs).
One of the best-known integrated care systems outside the United States is the Canterbury Health Board in New Zealand, which has been successful in moderating the rate of growth in hospital use by investing in services in the community. GPs and consultants in Canterbury also came together to agree health pathways for the diagnosis and treatment of patients with common medical conditions thereby breaking down barriers between clinicians.
Plans to establish ACOs in the NHS face technical and relational challenges. The technical challenges include the organisational forms needed when alliances of providers and commissioners are involved and the nature of the contracts and budgets required to turn plans into practice. Work is also needed on the incentives needed to enable providers to deliver the expected outcomes and share risks and rewards.
The relational challenges centre on the need to develop trust between the organisations and leaders involved as well as an ability to collaborate in a legal context that was designed to promote competition. These people and behavioural issues need serious attention in many areas and extend beyond organisational leaders to middle managers and clinical staff. The principal benefits of integration arise when clinical barriers are removed and this will only happen if frontline staff come together to redesign care.
These challenges are not insurmountable but they take time to overcome. Hardly surprising therefore that areas with a history of seeking to integrate services, such as Northumbria and Salford, are furthest ahead in establishing ACOs in England. Yet even in these areas, progress has not been straightforward, confirming the view expressed in the Next steps document that it will take time for these nascent arrangements to develop and mature. Common difficulties include how to engage GPs in emerging ACOs, and how to marry the very different forms of accountabilities in local government and the NHS.
Building strong relationships and cultures of collaboration takes time which is why the experience of established integrated care systems in the United States is generally more positive than that of recently created ACOs. Policy makers therefore need to be patient as emerging ACOs are established and avoid rushing to judge whether they are working. A process of trial and error supported by evaluation and learning is the best way of understanding what role ACOs have in the NHS of the future.
As somone who has defined sevice requirements for very large PFI's I know how this will go.
Gulp!!!! Be afraid.
Why are the press silent on this?
Late last year, Sustainability and Transformation Plans (STPs) were adopted in each of 44 areas covering England. Nationally, the plans seek to cut annual NHS spending by £22bn, by 2020/21. This aim was set out in 2014 by NHS England Chief Executive Simon Stevens in the Five Year Forward View, never properly debated. Stevens is a former health manager, Labour Councillor, advisor to Tony Blair and executive vice president of UnitedHealth Group, one of the biggest US private healthcare corporations.
£22bn is the gap between the predicted increase of £30bn required to maintain NHS services, and the Govt offer of £8bn, proclaimed as £10bn, actually £4.5bn, but under £1bn when adjusted for inflation in healthcare costs.
The cuts strategy began in response to the bank failures of 2008. Gordon Brown commissioned management analysts McKinsey, who recommended:
“The NHS in England could potentially capture efficiencies in health and healthcare services by between 15 and 22% of current spend, or £13 – 20bn, over the next 3-5 years. This reduction could come from
technical efficiency savings of £6.0 – 9.2bn found from provider costs
allocative efficiency savings of £4.7 – 6.6bn due to no longer commissioning low value added healthcare interventions and ensuring compliance with commissioners’ standards
savings of £2.7 – 4.1bn from a shift in the management of care away from hospitals towards more cost effective out-of-hospital alternatives”
In June 2009 NHS Chief Exec David Nicholson (supported by Health Sec Andy Burnham) challenged the NHS to find £20 billion in “efficiency savings” by 2015. That was how we, patients and staff, were to pay for their banking crisis. The Tories continued annual savings targets, now dubbed “Business As Usual”. Any fat in the system is long gone and efficiencies simply mean cuts.
Is the NHS unaffordable?
In 2007 the UK spent 8.4% of GDP on healthcare, in line with the average of comparable developed European economies like France, Germany, or Sweden. Now the UK is on course to reduce this to 6.9% by 2022/23, requiring massive cuts in services. However, even if health spending rose to 8.8% of GDP the NHS would still be affordable by 2030, the Nuffield Trust concluded.
The so-called NHS affordability crisis, is manufactured to support a unilateral Government decision to cut NHS funding.
Cheshire & Merseyside
Cheshire & Merseyside STP stretches from Macclesfield to the Wirral, and from Merseyside to Southport. It covers 2.5m people, 12 CCGs, 20 NHS providers, and 2 proposed Devolution regions. The plan aims to reduce annual regional spending from £6.8bn to £5.8bn. The STP was drawn up in secret, alienating local authorities who were supposed to be partners in a shift towards integrated care in the community, let alone the public or NHS staff. Management consultants PwC (formerly PriceWaterhouseCoopers) were paid £300,000 for work on the plan. As instructed by NHS England, the CCGs refused to release the STP until mid November, and never fully published the appendices.
Nationally, some Councils and Health and Wellbeing Boards backed away or even denounced the plans. On 1 Dec a 150 strong demo and sing-in at the Cunard Buildings attended the Liverpool Health & Wellbeing Board. Keep Our NHS Public, Defend Our NHS, Liverpool Against the Cuts, Merseyside Pensioners Association, GMB, Unison, Unite and Liverpool TUC, heard the Mayor declare “the proposals within the STP are rejected by the Council and this Board, because it fails to address the key issues facing our residents and their health in the years to come.” However, NHS England had already told CCGs to sign contracts for 2017/18 and 2018/19 by 23 December. Despite the chorus of rejection, the contracts were signed.
The STPs go far beyond cuts, to reconfiguration, privatisation, and aligning NHS structures with the formats preferred by US transnationals like UnitedHealth.
Last summer, the Countess of Chester Chief Exec briefed senior medical staff. A leaked email revealed that “the CEO suggested that at some point in future Arrowe Park, Clatterbridge and the Countess of Chester would be replaced by a single hospital somewhere near Ellesmere Port.” When MPs attacked the plan, it was denied but not ruled out, and it surfaces in the Wirral University Trust Hospitals Annual Report for 2015/16 as a long term aim.
The first STP target is A&E. In a survey of 99 CCGs, 31% said their STPs were likely to lead to closing or downgrading A&Es in the next 12-18 months. The Royal College of Emergency Medicine, Royal College of Nursing and the Royal College of Midwives all attacked the plans. 24 units are already marked for closure or downgrade.
The Cheshire & Merseyside STP is suitably vague, but the 21 Oct leaked version included:
Remapping of East Cheshire Trust elective and emergency care models.
Agreed long term models based on strategic relationship with University Hospital of South Manchester and Stockport FT.
Emerging clinical model: ED (Emergency Dept at Macclesfield Hospital) downgraded to MIIU (Minor Injuries & Illness Unit) staffed by GPs.
Agreed long term models for elective and emergency care in mid and south Cheshire based on strategic relationship with University Hospital of North Midlands: Mid Cheshire Hospitals cannot see any robust clinical links with Countess of Chester Hospital or Wirral University Trust Hospitals being sustainable given travel times and population distribution.
As to travel times, University Hospital of North Midlands is in Stoke. The existing Mid Cheshire A&Es are in Crewe and Northwich. From Northwich to Stoke is 37 min (27.5 mi) via the M6, if it’s not gridlocked. Macclesfield to Stockport is 38 min (12.3 mi) via the A523. NHS officials promptly denied the leak but the published plan is a smoother version of the same story.
The mid-Mersey region has adult A&Es in Southport, Whiston, and Warrington. The STP mentions 3 models of Urgent Care System:
3 Trusts will have a Type I – 24hr A&E (Consultant led 24 hour service with full resuscitation facilities);
3 Trusts will have a 24hr A&E (not specified as Type 1). High acuity patients will be transferred to the Emergency centre;
1 Trust will have a Type I – 24hr A&E, 2 trusts will re-profile opening hours with activity flowing to other 24/7 centres. This will lead to “Reductions in the consultant cover from 3 to 2 on call covering 3 sites” and “Activity transfer of 8,700-20,000 patients per year (one site).”
Yet A&E admissions and trolley waits are growing. From January to March 2014, St Helens and Knowsley had 29,400 emergency admissions and 180 patients waiting over 4 hours after the decision to admit. For Jan to March 2017, it had 41,393 emergency admissions and 1,284 trolley waits.
The Mid-Mersey plan also foresees “Ward reductions / closures based on reductions in Delayed Transfer of Care”. St Helens and Knowsley Delayed Transfers grew from 768 in Jan to March 2014, to 1,621 in Jan to March 2017.
“Back-office” is an insulting term for essential admin support services, mainly provided by NHS staff.
The STP aims to “deliver cost effective, efficient and commercially sustainable Back Office operations”. An Options Appraisal includes “Market Maturity Assessment” and “Identify Potential Providers”. The 30 June draft had 5 options: “– in-sourcing to best placed entities, consolidation of all the functions to a single location, setting up a C&M-owned Shared Services Centre, a joint venture with a private sector partner and outsourcing to the private sector.” It didn’t mention the debacle with Capita which led Liverpool NHS Trusts to take HR services back in house. It is also unclear how Cheshire & Merseyside can own anything, as the STP has no legal status.
Likewise, the STP aims to “deliver cost effective, efficient and commercially sustainable Clinical Support Services”. It mentions an STP wide C&M single managed Pathology service with plans to “Evaluate the potential for novation of contracts over time”. This sounds like a transfer of Path staff from NHS contracts to something else. The Medicines Information plan concludes “establish and transfer services”; another section mentions “new commercial vehicle(s) with proposed community pharmacy partner”. Meanwhile, Trusts may be allowed to use receipts from sales of land and buildings, i.e. transfers of assets from the public to private sector, to offset deficits created by underfunding. Expanding the use of digital technology will also transfer resources from the public to the private sphere. But computer systems are strong, stable, and foolproof, right?
In the long run the most dangerous aspect may be the drive to create “Accountable Care Organisations” which the STP mentions 18 times with no details or background. The obvious question is, accountable to whom?
Accountable Care is a concept from the US health insurance market, the last place you would want to look for inspiration. The idea is that a group of healthcare firms take responsibility for providing care for a given population for a defined period under a contract with a commissioner, such as Medicare. ACOs seek to lower costs whilst achieving pre-agreed quality outcomes. They ‘align incentives’ between providers and commissioners, sharing any savings between hospitals, doctors and Medicare. The overall savings to Medicare are small, or negative, depending on just what is measured.
Health Maintenance Organisations, run by the insurers themselves, were the previous incarnation. They involved routine denial of patients’ access to medically necessary treatment, fighting claims, screening out the sick, paying exorbitant CEO salaries, fraud, and hidden costs in top-ups and deductibles. ACOs have healthcare providers in the lead. But the same insurance firms are driving the process. Simon Stevens’ former employer UnitedHealth already has US contracts with over 800 ACOs, and recently launched its own NexusACO, aimed at 15 US markets.
ACOs can use ‘capitated’ fixed payments to providers for all or most of the care that their patients may require over a contract period, adjusted for severity of illness, and regardless of how many services are offered. Clearly, once the payment is in place, providers may offer only as much care as required by the contract. The specified care may not be comprehensive, and the defined patients may not be the geographical population, but built from GP registered lists. The key ACO models are the Multispecialty Community Provider, and the Primary and Acute Care System. Both models aim to reduce avoidable hospital admissions.
All the NHS ACO plans simply accept the massive funding cuts. They assume that pooling NHS and local authority resources, and expanding new models of care in the community, will justify cutting hospital budgets. The National Audit Office and the Nuffield Trust have demolished those assumptions. NHS England now stresses the development of ACO precursors dubbed Accountable Care Systems. Either version will transfer the funding shortfall from the National Health Service to self-contained localities.
Northumberland CCG is £31m in debt, and its flagship ACO plan, a primary and acute care system, is going ahead in transitional form. Currently, community and mental health services have fixed budgets, while the acute sector uses Payment By Results. The ACO will assign fixed budgets to all parts of the system. As the County Council puts it:
“These arrangements are intended to ensure that the ACO is in a position to take steps to bring about a shift of resources from hospital to community services across the board, while also bearing the financial risk if investment in community services fails to achieve the intended reduction in demand for hospital care.”
These risks are with the NHS partners. Northumberland says “the only significant new risks for the Council are the reputational risks arising from increased involvement in NHS planning at a time when continuing public sector austerity will require hard decisions to be made.”
ACO plans are now surfacing in Warrington, St Helens, and West Cheshire.
Warrington has agreed to pool CCG and local authority health and social care budgets, and is “determined to move away from a national tariff-based payment system to a defined capitated budget.” The ACO Board comprises Warrington Borough Council, the CCG, Warrington and Halton Hospitals, Bridgewater Community Health, Five Boroughs Partnership, and GP representatives. It will plan for:
Shared accountability and risk share
Pooled/aligned budget arrangements.
Commissioning / contracting from the ACO to the health and care market.
An appropriate vehicle for delivery.
Corporate Joint Venture and (full) Merger are options for the structure.
St Helens is setting up an “Accountable Care Management System” to involve the CCG, health providers and St Helens Council. In April 2018 it intends to transfer: Adult and Children’s Social Services (excluding Youth Justice), Public Health, Community Health, Adult Care (excluding maternity), Primary Care, Mental Health, Community Safety, Community fire safety, Mental health street triage, Victim support, Probation, Ambulance. Others may transfer later. The only permanent exclusions are Youth Justice, Community fire protection, and Road safety. St Helens is now considering whether the ACMS will compete for tenders as a collective, and if the ACMS will issue tenders and procure services from others.
The West Cheshire ACO will “segment our GP registered population by risk”. It will issue a Memorandum of Understanding between providers, who are “challenged to advise how they can release a material portion of their existing resources to enable this transformation”. It will also issue a “prospectus”.
The NHS is supposed to deliver evidence-based medicine, clinicians are educated on that basis, and new treatments are only licensed after passing rigorous trials and cost-benefit analysis. But evidence is tossed overboard when making policy based on confident assertions. Why should anyone put up with it?
The St Helens plan purports to list evidence for each of their plans. None of it is referenced. For example “Stand alone telephonic case management has been estimated to reduce admissions by 5%.” Says who? The Nuffield Trust says there is mixed evidence on case management. Research at the University of Manchester published in 2015 is entitled “Effectiveness of Case Management for ‘At Risk’ Patients in Primary Care: A Systematic Review and Meta-Analysis”. From the abstract:
“This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs”.
St Helens says “Social prescribing has saved Newcastle West CCG an estimated £2 – £7 million”. This is actually the Ways to Wellness programme which started in 2015 and runs for 7 years. It hasn’t been evaluated yet. Nuffield describes it as a “large scale trial”. The savings it will achieve are, at this stage, only projected.
Warrington says “Evidence shows that proactive planning using risk stratification is a key tool to improving outcomes”. Again, no reference. The Nuffield review found risk stratification tools still struggle to identify ‘at risk’ individuals before they deteriorate.
The private sector are helping to design the ACO plans. PwC are involved in Tameside, Wigan, Manchester City, Oldham, Cheshire, and St Helens. West Cheshire CCG appointed PwC to undertake initial ‘due diligence’. That’s PwC which audited Philip Green’s BHS empire before it collapsed.
In St Helens, PwC supports the Project Management Office in proposals for Governance, IT, Business Intelligence, Communications and Engagement. A Workstream stakeholder reference group has Specialist input from three people, two of whom are PwC staff. The St Helens ACMS is developing under the auspices of a People’s Board, including the Council and NHS providers, but also the Community Rehabilitation Company and Helena Partnerships. Helena manages former council housing. The CRC is a privatised probation service, 75% owned by Interserve, a facilities management company with PFI and other health service contracts.
The private sector is also funding new models of care. The Newcastle Ways to Wellness programme is an outcomes-based contract funded through a Social Investment Bond which includes £1.65m from Bridges Social Sector Funds. Bridges Fund Management describes itself as “Capital that makes a difference”.
Private sector involvement goes beyond the STPs. Locally, the new Royal is financed through PFI. Consultants were recently emailed on the Trust’s intention “to develop a strategy to increase its private patient activity. As part of its development I am writing to you all to determine if there is an interest in developing your private patient activity from the Trust.”
Privatisation does matter. PFI and procurement are wasteful and private healthcare can be dangerous. Last July, Virgin Care lost its contract to run Croydon’s Urgent Care Centre 3 years after the CQC found patients being streamed by untrained reception staff. 30-year-old Madhumita Mandal died after a receptionist failed to refer her to a medic, though she was in agony with a ruptured ovarian cyst. Virgin defended the streaming procedure.
The End Game
The implications for wages, terms and conditions of NHS staff when employers merge across care sectors under PwC guidance, with local structures which will threaten national agreements, are immediate.
Looking further ahead, no private company is big enough to buy the whole NHS. But once the STP plans are implemented and ACOs are established across England, health transnationals will see discrete local systems with budgets of £1bn or less, with structures compatible with the US health insurance market. ACOs could receive investment funds, or be bought and sold. Perhaps that’s why they need a prospectus.
Theresa May insists that the NHS will remain free at the point of use. Even so, she does not mean a comprehensive, universal service, with decisions on treatment made according to clinical need, publicly provided, publicly accountable, funded out of general taxation.
Labour have promised a case-by-case review of STPs. Given the involvement of Labour local authorities in these plans, and in Devo Manc, this will not be a simple argument.
If the Tories win the election, expect them to accelerate STPs and ACOs, with new legislation if needed. We will need active resistance if the NHS is to survive.
The Executive Summary has this about 'Electronic Medical Records', (EMRs) and 'Health Information Exchanges', (HIEs).
"Federal funding has essentially guaranteed the industry’s adoption of EMRs and HIEs...". "In the past six years, the U.S. healthcare industry experienced an unprecedented investment in software and technology, particularly EMRs and HIEs. Conservative estimates place that investment at over $100 billion. Despite those massive investments, there is no compelling or defendable evidence of any notable return on investment. The needle is not moving on the dashboard of U.S. quality of care nor per capita cost of care. To worsen the bleak picture, physician satisfaction with the EMR products stimulated by these federal incentives is only 39% and declining—six out of 10 physicians are dissatisfied with the EMR they must use to support the treatment of their patients. Seventy-eight percent of public HIEs fail due to financial insolvency after federal and state grant monies are removed from the model. One-third of the organizations in the CMS Pioneer ACO Program are dropping out because, despite their investments in EMRs and HIEs, these organizations are unable to adequately quantify the quality of care and financial risk for managing patients in the ACO."
The National Audit Office reported more than £10 billion pounds were written off in the failures of the "National Programme for IT" and its regional successors. No pilot of an ACO is to be tested in the UK. Where is the evidence for the proposal to introduce Accountable Care Organisations ?