Integrated or accountable care

‘Integrated care’ has become something of a buzz-word, but what it means depends on who’s talking.

There’s widespread recognition that patients may need care across different settings (such in hospital, and then either community or  social care when they are discharged), and that this care needs to be provided in a seamless kind of way. This type of integrated care at the ‘micro’ level is about improving  patients’ experience of healthcare by planning and coordinating it from their perspective. Unfortunately, at the moment, research shows that the financial constraints on NHS bodies and local councils are making this kind of ‘integrated care’ hard to achieve. (For example, lack of funding – for instance for social care  or district nursing – means that some patients cannot be discharged from hospital when they are ready).

However, the term ‘integrated care’ has also been adopted by some think tanks and those seeking a greater role for the private sector in health care provision, and they mean something quite different by this: in this context, ‘integrated care’ is used to justify the radical redesign of health services, ostensibly to make these ‘financially sustainable’. Despite assurances to the contrary, this understanding of ‘integrated care’ puts less emphasis on patients’ needs. Instead it focuses more  on integrating organisations and introducing new ways of working, payment systems, and so on that will keep health care systems under tight central control and ensure that they will cut costs in response to government underfunding. It is this second meaning of ‘integrated care’ that is being used by bodies like NHS England (NHSE) when introducing its ‘new models of care’.

Ironically the ‘transformation’ that the NHS in England is currently undergoing in the name of integration is actually fragmenting the NHS. It’s making local areas appear responsible for poorer services as a result of the underfunding from central government and – because of the variation in health need and resources between these areas –  will lead to health inequalities and regional differences in health provision.

Background

The idea of ‘integrated care’ in this second sense originates from, or at least has been advanced by, multinational corporations. For example, in 2012, the World Economic Forum –  an international organisation that describes itself as “providing a platform for the world’s leading 1,000 companies”  ran a project concerned with the financial sustainability of publicly provided health services, including the NHS. The project team, dominated by senior representatives from multinational corporations, was steered by Simon Stevens (then President of the giant US corporation, UnitedHealth Group, now head of NHSE). The team’s report, co-authored by global consultancy firm McKinsey and Co, offered governments a number of strategies to deal with the problems it identified, such as “the growing burden of chronic disease” and “patients’ raised expectations”. The report’s preferred solution was to lower costs by, for example, introducing new payment systems for organisations to encourage savings, cut services in higher cost settings such as hospitals, and get individuals to provide more ‘self care’. At the same time, the report argued that corporations should be allowed greater access to publicly run health systems like the NHS to provide new products and services while governments cut back on publicly provided care.

A year later, a second ‘sustainability’ WEF project took place, steered by Simon Stevens, among others, and reported again in collaboration with McKinsey and Co. This called for a shift towards ‘integrated care’ systems, such as the Alzira model developed in Spain (see below).

Integrated or accountable care and the NHS

It was shortly after these reports were published (i.e. April 2014) that Simon Stevens was appointed Chief Executive for NHSE (a non-governmental, largely unaccountable body), just six months before it  published its Five Year Forward View (5YFV). This plan for the NHS in England echoed many of the WEF’s proposals and argued for the integration of health and social care services.

This ‘integration’ was taken forward by NHSE requiring that England was to be divided into 44 geographical ‘footprints’, initially called Sustainability and Transformation Plans (STPs). These were later renamed Sustainability and Transformation Partnerships (ST Partnerships) and directed to set up systems in which the budgets of local authorities and local health bodies would be pooled, so enabling the joint commissioning of services.

Oddly, these integration plans fail to acknowledge the very different forms of funding for health and social care. Until now, NHS services have been free at the point of use (except for some services, such as dental care). In contrast, social care is provided on the basis of means testing and user charges. Not surprisingly, many see this integration of health and social care as a step towards introducing means testing and further charges for NHS care, especially at a time of unprecedented cuts and questions from some quarters about the financial sustainability of the NHS.

According to NHSE,  ‘integration’ is to be brought about by radical changes to the way care is delivered or what are called ‘new care models’, such as the Multispecialty Community Provider’ (MCP) and ‘Primary and Acute Care Systems’ (PACS) referred to in the 5YFV. These new models of care bring together different services (such as GP, hospital specialist and social care services) within one system in a way that NHSE has said is similar to the Accountable Care Organisations (ACOs) found in countries such as Spain and the US. The form most frequently referred to by NHSE, at least up til 2017, is the Spanish Alzira model.

In Spain, the Alzira model is based on a public/private partnership between local government and a consortium of businesses such as banks, construction firms and a private health insurer. (For more information on the Alzira model, see our page on Accountable Care Organisations.)

In the US, models of accountable care evolved from Health Maintenance Organisations (HMOs). HMOs, run by medical insurance groups, have been notorious for denying patients access to treatment; refusing policies to those with pre-existing conditions; and paying CEOs exorbitant salaries. ACOs were introduced to reduce spending while improving quality measures. The evidence that they do either is not convincing. They also aim to shift risk from payers (e.g. insurance companies) to service providers who are paid to manage outcomes and the health of whole populations rather than services provided.

However, it seems that HSE’s plans to entirely restructure the NHS through new models of care and organisational systems have been poorly thought through.  Until recently, NHSE’s ambition has been for most ST Partnerships eventually to become full-blown Accountable Care Organisations (ACOs), but because of the complexity of this process, ST Partnerships were expected to evolve first into what were initially called Accountable Care Systems (ACSs).

However, plans for ACOs met with considerable opposition from the public and the House of Commons Health Select Committee, among others, not least because these plans ran counter to existing legislation – for example, it seemed that the new organisational forms did not have the legal authority to redesign services.  They were also being introduced without adequate public involvement or meaningful consultation and without Parliamentary scrutiny. Extensive opposition, which included several campaign groups seeking judicial reviews, prompted a pause in the development of ACOs. And, because ‘accountable care’ had become something of a toxic brand, it was relabelled as ‘integrated care’, to be delivered by Integrated Care Systems (ICSs) (the new name for ACSs).

Footnote

In February 2017, the National Audit Office (NAO) produced a report warning that progress with integrating health and social care had, so far, been less successful than imagined; that it had not brought the expected benefits for patients, the NHS or local authorities; and that the aim to integrate health and social care services across England by 2020 was unlikely to be met.

The NAO’s report also found that NHS England’s ambition to save £900 million through introducing new care models may be optimistic. These new models are as yet unproven and their impact is still being evaluated. According to the NAO, there are an array of initiatives examining different ways to transform care and create financial sustainability, but the governance and oversight of these initiatives is poor. What’s more, the NAO found no strong evidence to show that integration in England leads to sustainable financial savings or reduced acute hospital activity.

Finally, despite all this talk of integration,

“… something else is barely mentioned these days: an integrated National Health Service, with integrated national clinical standards, nationally recommended treatments, national accountability, integrated funding through general taxation, integrated methods of allocating resources to areas of greatest need, an integrated national system of pay, terms and conditions for health service staff.”

See also our pages on

Sources and further information

For a fuller analysis of the World Economic Forum’s healthcare group, and its influence on redesigning the NHS, see https://www.sochealth.co.uk/2017/05/25/truth-stps-simon-stevens-imposed-reorganisation-designed-transnational-capitalism-englands-nhs-stewart-player/

https://keepournhspublic.com/nhs-bill/the-nhs-doesnt-require-reform-it-needs-a-revolution/

NHS England’s Five Year Forward View http://www.england.nhs.uk/ourwork/futurenhs

https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf

The Lords debate on the sustainability of the NHS https://opendemocracy.net/ournhs/richard-grimes/government-moves-to-consider-nhs-user-charges

 https://keepournhspublic.com/resources/resource-cabinet/ (see Accountable Care Organisations and Systems section)

Updated August 2018

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