Implications of ‘accountable care’

 In case you’ve not read the pages on  Accountable Care Organisations (ACOs) and Accountable Care Systems (ACSs), these are radical new ways of delivering care being introduced at breakneck speed: a number of service providers work together over a set period (e.g. 15 years) to take responsibility for the cost and quality of a specified range of health services for a defined population and for a fixed sum (a ‘whole population budget’). With ACOs, there is a single contract that establishes an organisation (either an existing or new organisation) that takes responsibility for deciding how to allocate resources and design services. It acts as a lead provider that can set up a series of sub-contracts with other providers.

In contrast, an Accountable Care System is an evolved version of a ST Partnership with responsibility for the health and resources for a defined population. Existing commissioning contracts remain in place. Commissioners, together with a network of providers across different services, enter into an alliance agreement and commit to managing resources together, along with agreeing governance arrangements and the sharing of risk and gain.

What are the issues raised by Accountable Care 

ACSs are in breach of the NHS Constitution: The introduction of accountable care has been dominated by NHSE’s drive for ‘efficiency savings’. Organisations within an ACS collectively agree to provide services to registered patients for a fixed budget, irrespective of the care that is actually needed or provided: even with minimum delivery standards in place, these whole population budgets provide an inducement to offer as little care as possible to minimise costs. This approach contravenes the first two principles of the NHS – to provide a comprehensive service, available to all, on the basis of need.

ACSs have no legal standing:

Despite the hugely significant changes being made following the 5YFV, the statutory framework of the NHS remains the same: changes is being brought about by administrative decree and being introduced through democratic process and the traditional use of white papers, primary legislation, public consultation and policy guidance. This means that there is now a conflict between the legal powers and duties of existing NHS bodies, as established by law, and the authority of new organisational forms, like ST Partnerships, that have no formal existence. So,

There are two sorts of change afoot – things which are in the Health and Social Care Act 2012 or other legislation, but which are simply being ignored or changed on the ground; and new ideas which don’t figure anywhere in the Health and Social Care Act 2012 or other NHS legislation, but which are being done anyway.

According to NHSE, ACSs will “create an effective structure for collective decision-making and governance” and Simon Stevens has announced that ST Partnerships will have governance rights over organisations within their local health system, including those bodies like CCGs or local authorities with statutory responsibilities. This is at best problematic and arguably illegal without legislative change: without new primary legislation the ST Partnerships that are setting up (or becoming) ACSs are not legal entities and have no powers to make decisions without referring these back to partner organisations.

ACSs and ACOs also represent a step away from the split between commissioners and providers enshrined in previous legislation such as the Health and Social Care Act (2012).

NHSE claims that ACSs will reduce costs by changing the current system for commissioning services by bundling them into giant contracts and reducing the costly annual round of purchaser/provider negotiations.  However, without new legislation to remove or amend the HSCA, ACSs will still be operating in the context of an expensive and wasteful market system.

 Increased privatisation of the NHS: With ACOs, the boundary between what is done by CCGs and providers will shift: ACOs will allow private companies a significant new role in the planning and commissioning of services, as well as their delivery, so escalating NHS privatisation. The single, large-scale contract that characterises ACOs is immensely attractive to private companies and makes it possible for multiple services to be put on the international market, allowing wholesale privatisation at one fell swoop.

By and large, individual ST Partnerships have no expertise in setting up ACSs and so they are spending significant sums of public money on advice from private consultancy firms, like Capita. One can only guess the extent to which these firms shape the new systems with their own future interests in mind.

Some fear that accountable care models will in themselves provide a structure that, in future, will facilitate the introduction of private health insurers. Notably, with ACOs in the US, the single contract is held by a public or private insurer.

Lack of accountability and public consultation: ST Partnerships are introducing ASCs with scant public involvement or consultation, despite the changes in service provision that will inevitably be involved. ACSs are presented as local bodies working in partnership with local communities but in reality, they will be run as businesses with little accountability to local people. This is in breach of the NHS Constitution’s principle that the NHS is accountable to the public, communities and the patients that it serves.

Centralisation of control: ACSs are being presented as a way for local organisations to get more control over the health system in their area. However, this is happening at the same time as increased direct financial intervention on the part of NHSE and NHS Improvement (NHSI), reversing the previous system in which clinical commissioning groups (CCGs) controlled the funding of services at local level.

Lack of evidence: There is little robust evidence to support the introduction of accountable care systems to the NHS, partly because pioneer programmes have, by NHSE’s own admission, been of short duration and provided only small sample sizes.

In the US, ACOs are relatively new, and vary in form, ranging from closely integrated systems to the looser alliances that are closer to ACSs in the UK. There is mixed evidence about their performance. The very different contexts in which the NHS and US health care system operate (not least the different levels of funding), and the lack of a standard model of care also makes it difficult to compare with the US experience.

Unrealistic expectations: ST Partnerships or their equivalents (such as ACSs) are expected to move towards a new form of financial control (a shared control total), in which financial risk is shared across the whole local health system. This means that individual providers within an ACS must set aside their own interests and allow any surpluses they make to be used to offset losses elsewhere within the system. In effect, each provider will police the spending of its partners. As, increasingly, many providers within an ACS will be private companies whose first priority legally is to make profit, they are unlikely to put aside their own interests for the good of the whole, especially as some NHS providers will be in deficit. Alternatively, this system runs the risk that public funding will support private companies operating at a loss.

Comment

No one can deny the need for acute, primary care and community NHS services to be better integrated. However, this is not what ACSs or ACOs will deliver. NHSE’s primary requirement of these new care systems is that they impose ‘efficiency savings’ on an unprecedented scale, widely recognised to be unachievable without savage cuts in services.

Accountable care systems that serve the interests of the private health industry while being of questionable value to patients are being introduced outside of any legal framework and without rigorous scrutiny by Parliament. We need new legislation, such as the NHS Reinstatement Bill, that protects the founding principles of the NHS, ends contracting and the marketisation of the NHS and re-establishes public bodies and NHS services that are accountable to Parliament and local communities.

 Further information

https://www.kingsfund.org.uk/sites/files/kf/Accountability-in-the-NHS-June-Kings-Fund-2011.pdf 

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