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.

Towards Integrated Care Systems

The NHS long-term plan set the ambition that every part of the country should be an integrated care system by 2021. Through our series of events, you'll gain expert guidance and practical insights from those leading the way to help you prepare for the transition.

Learn more

Comments

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.

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.

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?

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.

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.

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.

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.

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.

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

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.

Add your comment