Making sense of integrated care systems, integrated care partnerships and accountable care organisations in the NHS in England

This content relates to the following topics:

NHS England has recently changed the name of accountable care systems to integrated care systems, which describes more accurately the work being done in the 10 areas of England operating in this way. Our updated long read looks at work under way in these systems and at NHS England’s proposals for an accountable care organisation contract.

Why is change needed?

Constraints on NHS funding over the past seven years, combined with rising demand from a growing and ageing population, have put the NHS under enormous pressure. It has been clear for some time that simply working our current hospital-based model of care harder to meet rising demand is not the answer. Rather, the NHS needs to work differently by providing more care in people’s homes and the community and breaking down barriers between services.

Breaking down barriers means co-ordinating the work of general practices, community services and hospitals to meet the needs of people requiring care. This is particularly important for the growing numbers of people with several medical conditions who receive care and support from a variety of health and social care staff.

The NHS also needs to give greater priority to the prevention of ill health by working with local authorities and other agencies to tackle the wider determinants of health and wellbeing. This means tackling risk factors such as obesity and redoubling efforts to reduce health inequalities. And it means fully engaging the public in changing lifestyles and behaviours that contribute to ill health and acting on the recommendations of the Marmot report and other reviews to improve population health.

The NHS five year forward view, published in 2014, set out a road map for achieving these objectives. Several areas of England have been working to put in place the new care models outlined in the Forward View, and every part of the country has developed sustainability and transformation plans (STPs) describing how they will implement the Forward View locally. Building on these developments, NHS England’s update on the Forward View, published in March 2017, made the following bold statement.

Our aim is to use the next several years to make the biggest national move to integrated care of any major western country.
NHS England 2017, p 31

This aim is being pursued through the new care models, STPs and the evolution of some STPs into integrated care systems. These developments hold out the promise of a different way of working in the NHS with an emphasis on places, populations and systems. 

Successful integrated care systems will take more control of funding and performance with less involvement by national bodies and regulators. They will also have the opportunity to demonstrate what the Forward View is seeking to achieve through organisations working in partnership rather than competing. Partnership working is not easy in the context of the Health and Social Care Act 2012 which was designed primarily to promote competition, but some areas are finding ways of overcoming the obstacles and are improving health and care for their populations.

The aim of this briefing is to explain what is happening in practice drawing on our work with the NHS and local government. We describe developments in the new care models and integrated care systems and ask whether they are resulting in cuts in services and the privatisation of services. We also discuss what needs to be done to build on progress to date.

What are integrated care and population health?

Integrated care happens when NHS organisations work together to meet the needs of their local population. Some forms of integrated care involve local authorities and the third sector in working towards these objectives alongside NHS organisations. The most ambitious forms of integrated care aim to improve population health by tackling the causes of illness and the wider determinants of health.

Diagram showing the focus of population health systems

Developments in integrated care in England take different forms in different places. A variety of terms are used to describe these developments and this can be confusing and potentially misleading. For the purposes of this briefing, the following definitions describe the three main forms of integrated care that we have observed in our work.

  • Integrated care systems (ICSs) have evolved from STPs and take the lead in planning and commissioning care for their populations and providing system leadership. They bring together NHS providers and commissioners and local authorities to work in partnership in improving health and care in their area. 
  • Integrated care partnerships (ICPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.
  • Accountable care organisations (ACOs) are established when commissioners award a long-term contract to a single organisation to provide a range of health and care services to a defined population following a competitive procurement. This organisation may subcontract with other providers to deliver the contract.

ICPs are at various stages of development across England and ICSs have been established in ten areas1, two of which – Greater Manchester and Surrey Heartlands – are part of the government’s devolution programme. ACOs are also currently under discussion in a small number of places and NHS England is developing a new contract to be used by commissioners wishing to go down this route.

  • 1. The 10 ICS areas are: Blackpool and Fylde Coast; Berkshire West; Buckinghamshire; Dorset; Frimley Health; Bedfordshire, Luton and Milton Keynes; Nottingham and Nottinghamshire; South Yorkshire and Bassetlaw; Surrey Heartlands devolution area; and Greater Manchester devolution area. Four further areas have recently been selected to develop ICSs: Gloucestershire; Suffolk and North East Essex; West, North and East Cumbria; and West Yorkshire and Harrogate.

What’s happening with new care models?

A variety of new care models has been put in place to better meet the changing needs of the population. Two of these care models, primary and acute care systems (PACS) and multispecialty community providers (MCPs), seek to integrate care and improve population health. PACS and MCPs take different forms in different places but share a focus on places and populations rather than organisations. Both are examples of what we describe as ICPs and they have emerged without the need for competitive procurement. 

In PACS, hospitals often take the lead in joining up acute services with GP, community, mental health and social care services. The emphasis in MCPs is on GPs working at scale to forge closer links with community, mental health and social care services. The distinction between PACS and MCPs is being blurred as different care models evolve and increasingly converge. Both are focusing on integrating care and working to improve population health in their areas.

An advanced example of a PACS can be found in Salford, part of the Greater Manchester devolution programme, where health and care services are working in partnership to meet the needs of a population of 230,000. This work is led by Salford Royal NHS Foundation Trust which provides acute and community services, and adult social care services under a Section 75 agreement with Salford City Council. The trust collaborates closely with the mental health trust and work is under way to engage general practices in integrating care. The clinical commissioning group is collaborating with the local council to commission these services. The PACS in Northumberland is developing in a similar way.

An advanced example of an MCP is Encompass in east Kent where 13 general practices are collaborating to improve care for a population of 170,000. The MCP has five community hubs bringing together multidisciplinary teams of GPs, community nurses, social care workers, mental health professionals, pharmacists, health and social care co-ordinators and others. These teams manage the care of individuals who have been identified as being at high risk of hospital admission. Other initiatives include a database of voluntary and community services, a social prescribing service and drop-in dementia clinics. Early evidence suggests that these changes have led to year-on-year reductions in emergency admissions to hospitals.

What’s happening in integrated care systems?

Sustainability and transformation plans, or partnerships as they are now called, build on the work of the new care models and set out ambitions to integrate care and transform services. Forty-four areas of England prepared these place-based plans during 2016 as NHS England and other national bodies emphasised the need for providers and commissioners to collaborate in addressing the challenges they face. 

The update on the Forward View announced that some STPs would evolve into accountable care systems (ACSs) and these have since been rebranded as integrated care systems. These systems have no statutory basis and rest on the willingness of NHS organisations to work together to plan how to improve health and care. As they develop, it is expected that they will:

  • agree a performance contract with NHS England and NHS Improvement to deliver faster improvements in care and shared performance goals
  • manage funding for a defined population by taking responsibility for a system ‘control total’ 
  • create effective collective decision-making and governance structures aligned with accountabilities of constituent bodies
  • demonstrate how provider organisations would operate on a horizontally integrated basis, for example, through hospitals working as a clinical network
  • demonstrate how provider organisations would simultaneously operate as a vertically integrated system linking hospitals with GP and community services
  • deploy rigorous and validated population health management capabilities to improve prevention, manage avoidable demand and reduce unwarranted variations
  • establish clear mechanisms by which residents can exercise patient choice over where they are treated.

The quid pro quo for ICSs offered in the Forward View update was:

  • the ability for the local commissioners in the ICS to have delegated decision rights in respect of commissioning of primary care and specialised services
  • a devolved transformation package from 2018, potentially bundling together funding for the General practice forward view, mental health and cancer
  • a single ‘one-stop shop’ regulatory relationship with NHS England and NHS Improvement in the form of streamlined oversight arrangements
  • the ability to redeploy attributable staff and related funding from NHS England and NHS Improvement to support the work of the ICS.

The first 10 ICS areas were selected on the basis of the quality of their STPs and an assessment of their ability to work at scale to demonstrate progress in taking forward the ambitions of the Forward View. They vary widely in their size and complexity. Updated NHS planning guidance published in February 2018 states that other areas will become integrated care systems where they can demonstrate strong leadership, a track record of delivery, strong financial management, a coherent and defined population, and compelling plans to integrate care. A further four ICS areas were selected in May 2018.

The current ICS programme involves areas working with NHS England and other national bodies on a number of issues, including:

  • the governance arrangements and the leadership and staffing required to make a reality of ICSs
  • the financial arrangements needed, including the system control total, risk sharing and how services should be paid for
  • regulatory alignment and the implications for NHS England and NHS Improvement of working with ICSs
  • the performance contract with ICSs and the development of memoranda of understanding with NHS England with agreed performance goals
  • the development of population health management capabilities and a procurement framework to support this.

NHS England acknowledged in the update on the Forward View that the transition to ICSs was complex and would require a ‘staged implementation’. It also stated that progressing to an arrangement whereby commissioners would have a contract with a single organisation for the majority of health and care services and for the population health in an area would take several years. The proposed ACO contract is designed to enable this to happen but it is not yet being used.

What are ACOs and why are they controversial?

The language of accountable care originated in the United States at the time of President Obama’s health care reforms, and its use in the NHS has raised concerns that it could result in health and care services coming under the control of private companies. If ACOs are established in the NHS, they will be a means of delivering care and not funding it. The principles of a universal and comprehensive NHS funded through taxation and available on the basis of need and not ability to pay will not be affected. 

An ACO would take responsibility for the health and care of a defined population by managing a budget under a contract with commissioners awarded after competitive procurement. It would be similar to an ICP except that a single organisation would be awarded the contract and it would be a means of formalising the partnership agreements on which new care models and ICPs have developed to date. The contract could also involve a bigger role for private companies if they decide to enter the market.

The principal rationale for making the ACO contract available appears to be to enable GPs to lead the development of integrated care, building on the work of MCPs. One version of the contract would allow core funding for general practices to be included in the budgets controlled by ACOs, though many GPs would be reluctant to put their own income at risk in this way. The contract could also be used to commission services from ICPs developed through the PACS programme if commissioners and providers decide that a single contract would be preferable to using different contracts to integrate care. 

Previous difficulties in using competitive procurement to promote integrated care, as in the UnitingCare Partnership contract in Cambridgeshire, suggest that the ACO contract is likely to be used sparingly. To avoid a repetition of these difficulties, NHS England and NHS Improvement have put in place the Integrated Support and Assurance Process to provide guidance to commissioners and providers on the development of complex and novel contracts. Commissioners and providers will be expected to demonstrate that their plans to use the contract are robust before they can proceed.

The Department of Health and Social Care has consulted on changes to regulations to pave the way for the ACO contract to be used in the NHS, and this has given rise to two separate legal challenges. One of these questions the legality of ACOs under the Health and Social Care Act 2012 while the other claims that ACOs will lead to increased privatisation. Campaigners have criticised the government and NHS England for lack of transparency in developing their plans

In response, NHS England has decided to delay the use of the proposed ACO contract, and this offers an opportunity to listen to the concerns of campaigners and communicate why the contract is needed. The Fund’s work suggests that there is considerable misunderstanding about what is actually happening in the NHS and many of the concerns that exist are misplaced. NHS England needs to do much more to explain what the ACO contract would add to existing ways of integrating care and indeed whether it is needed at all at this stage in the development of integrated care.

How are integrated care systems and partnerships developing?

ICPs formed under the new care models programme are invariably led by NHS organisations, often in collaboration with partners in local government and the third sector. Their aim is to integrate care around the populations served and to do this by working in partnership and in some cases pooling budgets. In some areas an NHS trust acts as the lead provider in integrating care, while in others alliance contracts have been used to bring organisations and services together. ICPs are very much a work in progress and even the most advanced examples have much work to do to realise the potential benefits.

ICSs are at a much earlier stage in their development with Greater Manchester being the most developed. The largest ICSs include within their boundaries several ICPs that are very similar to those that have emerged under the new care models programme. As examples, Greater Manchester, with a population of 2.7 million, has ten ‘local care organisations’ (to use its own terminology). South Yorkshire and Bassetlaw with a population of 1.6 million is working to develop five place-based ICPs within its footprint.

Map showing the five ICPs in South Yorkshire and Bassetlaw ICS

ICSs in these larger areas are led by groups of NHS and local government leaders and are based on voluntary collaboration. Their principal functions are planning for the future, building on the work that went into STPs; aligning commissioning behind their plans; incorporating the regulatory functions of NHS England and NHS Improvement; managing performance in their areas; and providing leadership across the system covered by the ICS. Responsibility for service delivery rests with the organisations that provide care within ICSs and many of these organisations are collaborating to put in place ICPs.

The distinction between ICSs and ICPs is much less clear in smaller ICSs. For example, Blackpool and Fylde Coast (population 300,000) and Berkshire West (population 530,000) are working to integrate health and care provision in a way that closely resembles what is happening in ICPs. These areas and other ICSs with smaller populations may in time come together with their neighbours to develop the capacity to plan and provide system leadership across much bigger geographical footprints while also integrating care in place based ICPs.

What has this way of working achieved?

Early evidence from the new care models suggests some progress is being made in moderating rising demand for hospital care. 

Data collected by NHS England, for example, shows that PACS and MCPs in aggregate have seen lower growth in per capita emergency admissions to hospitals than the rest of England. Some new care models have reported absolute reductions in emergency admissions per capita. Among the eight ICS areas (excluding the Greater Manchester and Surrey Heartlands devolution areas), Frimley Health has also experienced reductions in GP referrals and flat A&E attendances, and the part of the Nottingham and Nottinghamshire area covered by the Mid-Nottinghamshire PACS has seen reductions in emergency admissions.

The experience of Frimley Health illustrates some of the service changes that have contributed to these trends. Drawing on the experience of the north-east Hampshire and Farnham PACS and similar work in Surrey Heath, GP practices have collaborated to provide same-day access to patients requiring urgent appointments, and community services have been aligned more closely with GP practices and adult social care. Mental health has been a particular priority and service users have worked with providers to improve access to a wider range of support. Hospitals have changed their ways of working in A&E to see and treat patients rather than always admitting them to a bed. The cumulative impact of many service changes lies behind Frimley Health’s success in moderating hospital use.

Greater Manchester provides further evidence of progress. Examples include improved access to GP services, investment in mental health services, and major changes to acute and specialised hospital service. Local care organisations across the conurbation are also building much closer links between NHS organisations and local authorities. This includes giving greater emphasis to prevention and population health as well as the integration of health and social care. 

These developments have been made possible in part because Greater Manchester was able to access its share of the national Sustainability and Transformation Fund to pump prime improvements in care and this has helped enable the area to make faster progress. Greater Manchester stands out because its work on health and social care is embedded within a broadly based and long-established public sector partnership led by local authorities. 

Other examples include progress in the Dorset ICS in making better use of acute hospitals through the designation of hot and cold sites in Bournemouth and Poole; work to moderate use of hospitals through closer collaboration between care homes, GPs and other services in the community, developed through new care models vanguards; and work in the Principia MCP in the Rushcliffe area of Nottingham where GP practices serving a population of 125,000 are collaborating to increase investment in primary care, support people to die in their home or preferred place of care, and reduce strokes. Principia, a partnership of 12 practices that is part of the Nottingham and Nottinghamshire ICS, is also breaking down barriers between hospitals and primary care by moving some specialist services into general practice and by GPs and community nurses reaching into the hospital.

The areas mentioned here all face the same challenges as the rest of the NHS in responding to rising demand with constrained budgets, but they indicate how new ways of working are beginning to deliver improvements in care. Their work also underlines the need for additional funding for the NHS as well as the need for new ways of working to sustain and transform health and care.

What do these developments mean for commissioning?

One of the consequences of these developments is that the commissioner/provider split that has underpinned health policy since the early 1990s is unravelling. Providers and commissioners are working together to establish ICPs and ICSs and some of the alliances of providers that make up ICPs are carrying out commissioning functions as subcontracting arrangements are put in place between lead providers and their partners. Clinical commissioning groups (CCGs) are either merging or agreeing to collaborate and are working closely with local authorities in many areas to develop joint or integrated commissioning. 

Commissioning in the future is likely to make use of longer term, outcome-based contracts. The current system of Payment by Results, which was designed for an environment in which choice and competition predominated, will then be superseded, in many cases, by population-based budgets. Commissioning will become more strategic and concerned with the funding and planning of new models of integrated care rather than the annual contract round that has added little value to the NHS in recent years. Commissioners will have a key role in holding providers to account for delivering outcomes agreed in contracts.

As discussed earlier, commissioners wishing to make use of the ACO contract will have to go through the Integrated Support and Assurance Process and demonstrate that their plans are robust. The alternative is to use existing contracts underpinned by agreements among providers to work in partnership as is happening in the new care models and ICPs. Current indications are that only Dudley and the city of Manchester are planning to use the ACO contract when it becomes available. Other areas that were considering its use have become more cautious because of the way the contract has become associated with privatisation.

Are these developments really a way of making cuts?

These developments are being implemented at a time when NHS finances are under huge pressure and, as a result, have been interpreted by some as a means of cutting spending and services rather than improving care. STPs were seen by critics as a way of NHS organisations working together to agree how they would live within the financial envelope available to them. Guidance from national bodies reinforced this perception with the requirement that plans should show how they would bridge the financial gap facing the NHS.

While financial issues are very important in ICPs and ICSs, it would be wrong to see the developments described in this paper as first and foremost a means of the NHS balancing its books. Recognising that the NHS is required by parliament to keep within its spending limit, and that this is proving difficult, these developments are primarily about improving health and care, and in so doing seeking opportunities to deliver its financial objectives. Integrated care and population health should not be expected to save money but have the potential to enable resources to be used more effectively.

ICSs are an attempt to give local leaders more control over the use of the collective resources at their disposal, thereby enabling them to back the ambitions set out in STPs with flexibility to move money around. Recent NHS planning guidance emphasises this point and indicates that ICSs will assume responsibility for a system control total for their areas. This will enable them to support organisations that are in deficit by drawing on surpluses from organisations that are performing well, provided that the system as a whole achieves financial balance.

Will these developments lead to privatisation?

The proposed ACO contract could result in more NHS services being managed by private companies but this seems unlikely to happen in many cases. To begin with, only a few areas have expressed an interest in using the contract; others are using existing legislative flexibilities to develop integrated care. The area furthest ahead in its plans to use the contract, Dudley, has identified two NHS trusts as the preferred providers, working with general practices involved in its MCP.

Another reason why private companies are unlikely to be favoured is that the ACO contract will require bidders to have the capabilities to deliver a wide range of NHS and related services. These capabilities do not exist among private providers currently working with the NHS as they deliver specific services rather than comprehensive care. NHS organisations working individually or in partnership are much better placed to take on the contract, and national NHS bodies are reported to be exploring how a new form of NHS organisation might be used for this purpose.

The experience of Hinchingbrooke Hospital in Cambridgeshire, where the private company, Circle, had to hand back its contract to provide NHS services because of insufficient funding suggests that there are limited opportunities to generate profits from NHS contracts. This is not surprising when deficits are endemic among NHS organisations following several years of austerity. It is hard to envisage how private companies would perform better financially than NHS organisations when they would be taking responsibility for the services provided by these organisations if they competed successfully for an ACO contract.

It would also be wrong to see ICSs and ICPs as a means of privatising services. They have emerged through the leadership of NHS organisations rather than via market testing and they are an example of partnership working in the public sector. Private providers may be brought in by NHS organisations where they have distinctive expertise to offer, for example in providing analytical support, but this has occurred throughout the history of the NHS and is not the result of the developments discussed in this paper. 

Rather than opening up the NHS to increased privatisation and competition, as some have claimed, these developments are likely to have the opposite effect. The vestiges of market-based reforms remain, but they have taken a back seat as the need for NHS commissioners and providers to work together to make decisions on the use of resources has been given higher priority. The risk this creates is the possibility of legal challenges from private companies who feel that commissioners are not using competitive procurement as required under the law and instead are keeping contracts within ‘the NHS family’. 

Where next?

The challenges in making progress are real and should not be underestimated. They include the following.

  • The need to ensure that national regulators change their ways of working (rapidly) to support developments in the NHS. An example is the way in which the Care Quality Commission (CQC) has put in place local system reviews that assess how well organisations are working together to meet the needs of their populations.
  • The need to avoid creating another tier of management by incorporating the work of NHS England and NHS Improvement into ICSs and aligning and streamlining commissioning behind ICSs and ICPs, as is beginning to happen in some areas.
  • The importance of local leaders investing time and effort in building trust and collaborative relationships and overcoming competitive behaviours that in the past have created barriers to partnership working.
  • The importance of demonstrating tangible improvements in health and care while at the same time putting in place the governance, leadership and funding models needed to support integrated care.
  • The need for clinicians to be at the heart of integrated care developments, building on the work of the new care models and recognising that the principal benefits of integrated care result from clinical integration rather than organisational integration.
  • The need for politicians and national leaders to allow sufficient time for integrated care to become established and deliver results, recognising the growing pressures on the NHS to tackle the financial and service challenges confronting the health and care system.
  • Linked to this, the risk that the behaviour of regulators will undermine moves to system working if they resort to top-down performance management to address performance challenges rather than relying on ICSs to take the lead in so doing.
  • The importance of engaging fully with local authorities and other partners and avoiding an NHS view of the world taking precedence.
  • The need to put in place incentives (financial and non-financial) to stimulate emerging models of integrated care to deliver improved care and outcomes for their populations and avoid becoming unresponsive monopolies.
  • The need to engage a wide range of stakeholders, patients and citizens in the work that is under way, to listen to their concerns about the ACO contract and other issues, and to involve them in developing new care models and integrated care in a transparent process.
  • The need to clarify the likely end state of current developments to provide greater certainty about the direction of travel for local leaders who are working to develop integrated care for their populations.

Conclusion

The King's Fund believes that the developments discussed in this paper should be supported because they offer the best hope for the NHS and its partners to provide the health and care services required to meet the needs of the growing and ageing population. They will not deliver results quickly which is why national and local leaders need to make a long-term commitment to developing integrated care as the main way of providing and funding care in the future. Integrated care is not a panacea and unless implemented with skill it will not deliver the improvements in health and care envisaged in the Forward View.

Changes in legislation will be needed to align current developments with the statutory framework. There is no prospect of this happening in the short term because the government lacks a working majority and because Brexit is dominating the parliamentary timetable. For the foreseeable future, the NHS and its partners will have to find ways of making progress through workarounds, hoping that the political will can be found before too long to bring the law into line with the priority being given to integrated care.

The difficulty this creates is that workarounds are unstable, even in the most favourable circumstances. They depend on NHS organisations putting in place governance arrangements such as memoranda of understanding and partnership boards that enable them to make progress within the existing statutory framework. These arrangements are a way of formalising the work being done in ICPs and ICSs and respecting the statutory roles and accountabilities of NHS organisations, local authorities and other partners. 

Their effectiveness hinges on the willingness of local leaders to work in this way and if necessary to give up some of their own sovereignty for the greater good of the populations they serve. ICPs and ICSs could be derailed if any of the partners decide to withdraw, even when national NHS bodies are making it clear that they see this way of working as being the future for the NHS. While existing flexibilities have been helpful in enabling progress to be made in many areas, they will be severely tested by continuing financial pressures.

The biggest risk to integrated care is organisational protectionism, rather than privatisation, linked to a history of competitive behaviours and sometimes poor relationships between the leaders who need to collaborate to make a reality of integrated care. Our own work has found that progress is more rapid where effort has been invested in building trust and collaborative relationships. This must be done at a local level and it takes time and requires sustained commitment.

The promise of integrated care will only be delivered if doctors, nurses, allied health professionals, pharmacists and many others in clinical roles work much more with each other and with staff working in social care and the third sector around the patients and populations they serve. There are examples of this happening in the new care models and related initiatives like the primary care home pilots as well as in international exemplars such as the Canterbury health system in New Zealand. The NHS and its partners must act on learning from these examples, otherwise services will remain fragmented even if organisations become more integrated. The worst possible outcome would be another reorganisation of NHS structures that fails to improve care.

The other big risk is the ability of experienced leaders to find the time to develop new ways of working while also tackling the huge operational pressures facing the NHS and social care. It is a truism that the urgent tends to drive out the important and it would be understandable if the development of integrated care were delayed as a consequence. To return to the starting point of this paper, operational pressures cannot be managed simply by working harder, they require the development of new care models better able to meet rising demand for care in the community as well as in hospitals. This is the raison d'etre of integrated care and why it should be supported.

Comments

David Peach

Position
Retired,
Organisation
NHS User
Comment date
22 February 2018

Section dealing with-: WILL THESE DEVELOPMENTS LEAD TO PRIVATISATION NHS services being managed by private companies (1)Will this lead to the American Health Care industry (Which is favoured through KPMG involvement which were invited by the Tory hierarchy to instruct them in the so called new NHS model). Not long ago the Tory PM had hinted in American Healthcare Organisations being involved with OUR NHS, realising the slip then quickly retracted. (2) Only a few areas expressed an interest using this contract, Question which organisations led you to this conclusion, was the hand picked CCGs selected and controlled by the Department of Health expressed an interest, or was it decided democratically by NHS medical staff and NHS users with no interference from the D.O.E. . Also as with what happened with Richard Branson, threatening to sue the NHS if he didn't get a lucrative contract and the Department of Health conceding to his demands, surely this will lead to others i.e. USA and UK organisations following suit. like with the Private Nurses bank which drained the Hospitals budgets which the TRUSTS allowed. Using more private health will decimate the NHS budget which will satisfy those involved with this New NHS Model and those who want to de-nationalise . I would be pleased if would try answering the questions instead of fobbing me of to different websites

Andy Kliman

Position
Director, Health,
Organisation
Lexington Communications
Comment date
22 February 2018

A wonderful and clear report that pulls all the different strands together into a concise narrative. Two points I would want to emphasise are, firstly the lack of clear data or use of data within STPs. No STP should even dream of becoming an ICS without first knowing who their at-risk patients are. From my time in the NHS I couldn't believe that this crucial information wasn't front and centre with every CCG. Secondly, the report rightly points out the need to engage with clinicians, patients, citizens and local stakeholders, but the report should have gone further and outlined the duty of CCGs to engage. In an ICS/STP setting engagement should also be a collective endeavour.

Mr R W Ebley

Position
Retired,
Comment date
22 February 2018

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

Roger Steer

Position
Director,
Organisation
HAC
Comment date
22 February 2018

Integration is a false god that should not be worshipped.
It replaces choice and competition, past false gods seemingly consigned to history but alive in the Health and Social Care Act.
But integration is neither a sufficient or a necessary condition for success.
It requires organizations and individuals to act against their own interests and against the law in pursuit of a faith that integration will lead to the promised land.
It will not.
The reality is that the NHS is being sliced and diced into readily contracted out portions with inadequate specifications, controls, and safeguards.
By all means, experiment along these lines but it would be nice to see the results, evidence it works and does not just add another costly administrative tier on top of the NHS before being sold off the back of the lorry.
Accountable care organizations in the USA add 15% to the costs of healthcare. It will take some convincing to persuade people that establishing comprehensive contracts for monopoly provision of healthcare over 10-15 years and contemplating handing these to the private sector is a wise policy. The formula that this is not private funding but private delivery is not especially reassuring.
And if the intention is merely to recreate old health authorities working together under the yolk of cash limits to do their best with a blank piece of paper say so. But if that is the intention what is all the talk of accountable care organizations, draft contracts, legal manoeuvres to escape transparency and scrutiny in detailed planning, and huge bills from management consultancies all about?
It is a mess, and just ploughing on is not going to get the NHS out of it.

Mike Hope

Position
3 - but all related to Neurorehab,
Organisation
Thompsons/Recolo/self employed
Comment date
22 February 2018

Chris Ham - you can do better than this!
You are not stupid and neither I suspect are people reading this
So please let's really explore these issues properly, rather than trying to pass off ACOSs/ACOs as developments which are sadly being misunderstood by everyone from Stephen Hawking to Jeremy Corbyn to Polly Toynbee.

First - the money.
You start your article by acknowledging current NHS severe financial constraints. This is obviously true. But rather than treating it like some unfortunate objective phenomenon (like bad weather) as you seem to do, why do you not mention that underinvestment in the NHS is a deliberate political policy. It has been the policy of Governments since 2010 and very much remains in place now (see November budget). But with current political volatility this is now very much called into question. Many of us see that 'it doesn't have to be like this', and our number is growing.

This is crucial to the ACS/ACO project (sorry, I will not use the 'integrated' word purely because it saves NHSE's and J Hunt's blushes). These contacts when they come will be predicated on fixed (and, according to current political leaders, immutable) budgets. There will be no more money, we are told. So ACSs/ACOs are conceived as a way of making limited spending more efficient. Little wonder then that there is concern. Added to which the 'accountable' bit in the original AC description does not mean democratic accountability. It means accountability to the spreadsheet. Thus the financial heart of these contracts will driven by models of accounting which do originate in US healthcare thinking.

Little wonder then that NHSE and Mr Hunt have so far been very covert in their rollout of this project. A public debate on the principles underlying it is the last thing they want until or unless they can control the narrative. So perhaps it is naive to express surprise, as you have, that these issues have not been propely aired in public.

Second - the 2012 NHS and Social Care Act.
This legislation is still very much in force. As you say, it underpins the recent marketisation of the NHS. In terms of contacts, it means that 'any qualified provider' has to be considered. To go against this leads to the threat of legal action (see Virgin Care). As we know, many of the usual suspects who bid for contracts are past masters at winning bids for themselves, (against in-house NHS and voluntary sector competition) when they must know full well that they cannot deliver in the longer term. This fact of life does not deter them however from trying again and often winning again. The Act allows them to do this everlastingly. Thus whatever the local preferences might be, and after much initial legwork by NHS and sometimes Social Care organisations , there will be nothing to stop these characters gaining ACO contracts in the longer term. Only the abolition of the Act and its terms will make them cease.

Third - Integration.
Given that the aim, as you explain, of the ACS/ACO trajectory is to bring different elements of Health and Care together, to get different organisations (including within the voluntary sector) working together around longer and more person-centred care and treatment pathways which snake out into the community, is this likely to happen? I would say here that as someone who has spent his last 20 years focusing on the lifelong rehab needs of a much under-diagnosed and under-considered group of people (those with various acquired brain injuries), there is nothing I would welcome more than genuine integration of services. It is what I have worked towards. However, it won't happen like this. The very logic of the market, which still holds sway, and of the behaviour of the aforementioned private corporations if they become contract holders, will mitigate against integration. It will lead to fragmentation. And discontinuity (as one private company buys out another). And focus on the short term not the long term. And a failure to be held to public account (there are so many recent examples of this that it becomes a 'given'.)

Those of us who desperately want sustainable integrated services and person-centred planning, rather than box ticking, should actually look to a refounding of the NHS, reaffirming its original principles in terms of the right care at the right time for everyone, at no cost to themselves, and with a particular emphasis on social justice. Involving Local Authorities and the network of often small local voluntary sector groups in this will be crucial, not as an afterthought but as integral partners. This will involve a new social contract between the NHS, Local Authorities, and communities, and a revived sense of civic purpose. And there is evidence that there is more public appetite for this there has been in my lifetime. Another world might just be possible...............

Jenny Rivett

Position
retired ex SRN and deputy Foundation Stage manager,
Comment date
22 February 2018

Quotations I take umbrage at
"by population-based budgets."

"Rather than opening up the NHS to increased privatisation and competition, as some have claimed, these developments are likely to have the opposite effect. The vestiges of market-based reforms remain, but they have taken a back seat as the need for NHS commissioners and providers to work together to make decisions on the use of resources has been given higher priority. The risk this creates is the possibility of legal challenges from private companies who feel that commissioners are not using competitive procurement as required under the law and instead are keeping contracts within ‘the NHS family’. "

So the law needs changing!!

And how can anyone predict the requirements of health care based on a local population ... while claiming that

"If ACOs are established in the NHS, they will be a means of delivering care and not funding it. The principles of a universal and comprehensive NHS funded through taxation and available on the basis of need and not ability to pay will not be affected. "

Who provides the extra funding when your population ill-health excedes the local budget???

I agree with Mike Hope's last paragraph

Gaynor Lloyd

Position
Steering Group member,
Organisation
Brent Patient Voice
Comment date
24 February 2018

Dear Mr Ham,
a few questions from an old lawyer:
1 Evidence for your "long read" - what is the "Fund's work" ( as in the sentence:" The Fund’s work suggests that there is considerable misunderstanding about what is actually happening in the NHS and many of the concerns that exist are misplaced.")?
2 Who in their right mind - never mind GPs who apparently show some healthy concern - would enter into an "arrangement" to deliver part of an integrated care contract with "risks and incentives" without its being an enforceable contract on which all parties must have full legal advice on the risks to themselves and precisely what their contractual obligations wil be, and, e.g., what happens if any part of the "partnership" pulls out? (even as "small" a component part as the odd GP going back to his/her GMS contract)? Who is paying for that individual advice and negotiation for anyone signing up and taking the risks? "Trust" and "collaboration" just won't hack it; long gone are the days of "My word is my bond".
3 What about the data sharing all this is predicated on? OK, no need for consent for direct medical purposes with clinical team members in most cases but social care? Identifiable in our case in NW London, as we have just found out. And with other parties? You have to have explicit, informed individual consent with the whole rationale and proposed use of the data explained to each sharer even under the current Data Protection legislation but the General Data Protection regs coming in in May 2018 are much stronger, and the penalties on data controllers (like GPs) and data processors are phenomenal. So explain how these rebranded systems are going to work legally, please with lawful data sharing? I look forward to hearing.

Nick Mann

Position
GP,
Organisation
NHS
Comment date
24 February 2018

Prof Ham states that ICS won't save money, which is problematic for the 44 STP areas obligated to save £22bn. In fact, if 'care closer to home' is realised - ie not just a euphemism for remote access and monitoring in the face of resource reduction - it will cost more.

The growing and ageing population is a longer term issue, in no way causative of today's unprecedented NHS crisis.
ICOs therefore are not a way to obviate this crisis in the short or medium term.

Integration as described in this article is not new: health & social care, 1ary & 2ary care, community working, all exist already with both benefits and hindrances to care and efficiency.

Reversal of fragmentation and further integration are dependent primarily upon repealing the H&SC Act. "Workarounds" render the whole system incoherent and vulnerable to destabilisation, complex contracts and instability of providers. Virgin has already shown its willingness to sue the NHS.

Ham reassures us that private companies have neither the intention nor the capacity to pursue contracts in this non-NHS brave new world. This is a peculiar assertion, given that Simon Stevens himself was lobbying pre-TTIP on behalf of an alliance of major US Health Companies, to have access to the UK Health market. Furthermore, UK Health services are almost certainly on the table for impending UK-US trade deals.
As for capacity, UnitedHealth has a turnover equivalent to the NHS's annual budget, and Virgin has shown no reluctance to continue its 'loss-making' expansion in the NHS.

5yfv new models include private equity and private providers, so it's unclear what end is being envisaged here.

If the intention is to effectively recreate District Health Authorities, then let's just do that. In law.

Further work on integrated funding and service delivery can then be achieved with confidence, and the full support of clinicians.

But absolutely no further reorganisation should take place until the funding, staffing and beds crises have been resolved. As yet we have not seen any political will to do this.

Nicola Kingston

Position
Patient Voice,
Organisation
London Clinical Senate
Comment date
27 February 2018

Love Mike Hope's idea of developing a new social contract - Think this is one that Chris Ham and colleagues could develop the thinking on- considering the role of Leadership and governance for integration.
The local authorities and voluntary sector seem to play less of a role in recent guidance- and the role of people power seems to have been downgraded from the excellent chapter in the original 5YFV.
But communities and their involvement, and development of informal carers to pull everything together in Local Care Networks
under local leaders may be the way to ensure local people are involved in decision making, and also in delivery of improvements.
KF work on Nuka might be a great start, and looking at exemplars such as Bromley by Bow and My care My way could be really helpful.
The other thing that needs to be developed with communities is Outcomes measures that have been developed by local people and are measured by them too - again the role of community researchers at Bromley by bow looks terrific. Of course we will need hard data from Public Health too, but many tend to be retrospective and generalised and not specifically linked to interventions, and for IHI style improvement we need weekly or monthly measures.
How about it , Chris?
Those of us who desperately want sustainable integrated services and person-centred planning, rather than box ticking, should actually look to a refounding of the NHS, reaffirming its original principles in terms of the right care at the right time for everyone, at no cost to themselves, and with a particular emphasis on social justice. Involving Local Authorities and the network of often small local voluntary sector groups in this will be crucial, not as an afterthought but as integral partners. This will involve a new social contract between the NHS, Local Authorities, and communities, and a revived sense of civic purpose. And there is evidence that there is more public appetite for this there has been in my lifetime. Another world might just be possible...............

Dr John Ribchester

Position
GP. Chair and clinical lead for Encompass MCP,
Organisation
Encompass MCP, kent and Medway STP.
Comment date
01 March 2018

At the risk of swimming against the tide of the naysayers, I think Chris Ham's long read is an excellent description of what is currently known. I am circulating it locally as a recommended read.
As stated, these developments are works in progress, so much detail is yet to emerge.
Speaking as someone representing an MCP which has achieved some success (ref this week's HSJ article) I can see and measure the improvements in patient care, patient experience and staff satisfaction from our work, and that of others. Place based care, with GP at scale at its centre is surely to be encouraged. The evidence of increased efficiencies, both clinical and financial, are beginning to emerge. These should be spread at scale and pace, for the sake of our health and social care and everyone in need of it.

Dr Paul Buss

Position
Medical Director,
Organisation
Health Board
Comment date
01 March 2018

This read represents an excellent road map towards (in my view) a better, more sustainable, health and social care service. It outlines a number of possible routes to reach a population based and outcome focused end point through the development of more integrated systems of care.

However this cannot come to fruition without a different simultaneous change to to the financial infrastructure. This must become more clinically aligned and evidence based but more outward facing. It needs to employ the concept of clinical value in order to rapidly deliver better vfm from new "clinical/social care commissioning" and has to build upon the very old welfare economic concept of social value to deliver in practice.

A must read for my clinical colleagues in clinical leadership positions

d.spencer

Position
Retired IT technicion,
Comment date
01 March 2018

The NHS has always been a target for various governments, but this one is determined to privatise what it can, and destroy what it cannot. There does not need to be any doubt whatever, we are seeing the likes of Virgin being handed contracts across the UK for a whole range of services. Health and Social Care Act,.... section 75 ....competitive procurement.....it does not matter, an ACO or ICS, call it what you will, integration will lead to public services being contaminated, degraded, spoilt by grubby private profit seeking organisations. I look forward to the day when a Socialist Government takes back all these services into an NHS whose ethos is compassion, care for the sick, valuing the staff. No compensation to the grubby second car dealers currently running so much of our NHS.

Chris Ham

Comment date
02 March 2018

Thanks to everyone for their comments on my long read. Let me respond to some of the points.

The long read is based on our work at the Fund and this involves working with the 10 integrated care systems and also with many of the new care models that are developing integrated care partnerships. I have seen at first hand what is happening from Northumberland to Cornwall and many places in between. Our assessment is based on empirical understanding and not theoretical arguments about what might happen.

We've argued consistently that the NHS and social care are underfunded. Please see various reports on our website, most recently around the Nov 2017 budget. The long read does not reiterate these arguments because they are covered extensively elsewhere.

We share the view that changes in the law will be needed but there is no prospect of that happening in the short term because the govt does not have a working majority and Brexit is dominating the parliamentary timetable. If you believe that integrated care should be supported, as we do, then ways must be found within the law as it is to make progress. This is what's happening in many of the new care models, making use of existing flexibilities, and some positive results are emerging as the long read explains.

We support the argument for a new social contract or compact with the public. We are working on this as part of our contribution to celebrating the NHS at 70 and there are more details on our website. We are bringing this work together at the end of June in a debate with senior politicians informed by deliberative events with members of the public.

Finally, integrated care is not a panacea but it offers the best hope of meeting the needs of a growing and ageing population. The benefits will only be realised if the emphasis is placed on clinical and service integration. Organisational integration may follow but the developments currently underway will fail if they are just another restructuring of the NHS and social care. We set out the evidence on integrated care in a report I wrote in 2010 with Natasha Curry (also on our website) and are heartened that at last some of this thinking is bearing fruit, as in the work of John Ribchester and others.

Andrew Holden

Position
GP / Primary Care Lead,
Organisation
SE Hants CCG
Comment date
07 March 2018

I am surprised your summary of NCM / ACO / STP / MCP / PACS etc makes so little reference to that fact that for success they must all involve the patients / clients themselves changing their health-seeking behaviour and the significant changes that involves. I am sure that models like Encompass in Kent make short term reduction in parameters such as A&E attendances (not actual savings) as we have experienced locally too, but to achieve longterm success this is probably the most important factor apart from recognising that medical advances are costly to implement and fund.

John Kapp

Position
director,
Organisation
SECTCo
Comment date
20 April 2018

Thanks, Chris, but you are fiddling while mental patients mind burn. Get back to the point of the NHS, which is to provide patients with evidence based (NICE recommended) treatments that work, but for mental disorders, GPs can only prescribe antidepressants which are not NICE recommended because they do not even claim to heal or cure, but which have harmful side effects which are often worse than the disease. They have been marketed for 40 years, and have turned nervous breakdowns (which affected less than 1 in 1,000) into an epidemic of long term conditions affecting 1 in 10, and which the WHO predicts will soon become the biggest disease burden for humanity. The solution is medication to meditation by mass commissioning iAPT, and decommissioning drugs.

Laura J Welti

Position
CEO/Manager,
Organisation
Bristol Disability Equality Forum
Comment date
28 April 2018

I share the view of many that you have given insufficient consideration of the impact of current legislation, overseas market interest of private sector organisations and post Brexit trade agreements in stating that ACOs do not pose the privatisation threat that many see as a very real risk.

We have a government that is desperate to strike trade agreements with countries outside the EU and to do so quickly for largely party-political expediency. One on the horizon is with USA, which in turn is led by a President that believes 'throwing his weight around' is the best way to secure his country's interests. The USA showed its 'preferred terms' of trading in the TTIP proposals which substantially threatened food, agro-chemical, drug and nation-run service provision security. Yet you don't even mention the capacity of the privatised health services in the USA to take on ACOs, instead only commenting on the immediate 'readiness' of the UK market to take on an ACO.

Forgive me if you find the phrase undermining but, to me, this seems exceedingly niave.

Revd Paul Brothwell

Position
Chairman,
Organisation
Kidderminster & Worcestershire Prostate Cancer Support Group
Comment date
20 August 2018

When you talk about integrated care, What is the role of Support Groups an the Third Sector in all this?

Pearl Baker

Position
Carer/Independent Mental Health Advocate and Advisor,
Organisation
Independent
Comment date
22 August 2018

The National Audit Office (Protector of the Public Purse) 2018 Report should be read. It says more Privatisation is inevitable.

I am afraid Health and Social Care is ‘doomed’ the third sector or even Carers are rarely mentioned, yet we save the Country Billions.

ACO ( USA) terminology was replaced with ICS ( they? thought more acceptable..

I am afraid the only way for Carers is to research your rights and those
you care for and’fight’ for your rights. Personal Budgets available for most in the system? and arrange your own Health and Social Care.

JCEH

Position
Analyst,
Organisation
Optum
Comment date
19 September 2018

Links to evidence, please. When I hear things like a reduction in A&E attendances / admissions I want to see the evidence for myself. More importantly, that evidence has to be reproducible from relevant data sources, e.g. HES. That's one of the problems with NHS commissioning: people spout opinion and conjecture as facts. For them to be facts the methodology needs to be reproducible and verifiable. Until then it is nothing more than gossip.

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