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 should patients need care across different settings (such as in hospital and then either community or  social care when they get home), it’s best that care can 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 it from their perspective. (Alas, research shows that the financial constraints on NHS bodies and local councils are making this kind of ‘integrated care’ hard to achieve.)

However, the term ‘integrated care’ is also being used by bodies like NHS England (NHSE) at a broader, or macro, level to argue for the radical redesign of health services in order to make ‘efficiency savings’: as funding for the NHS has been near enough frozen for the period 2015-2020 yet NHS costs and pressure on services grows, ‘efficiency savings’ inevitably means cuts.

Background

Notably, ‘integrated care’ in this macro sense has been promoted 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 run health services, including the NHS. The project team, dominated by senior representatives from multinational corporations, was steered by Simon Stevens (then President of a US corporation, Global Health). Its 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, cutting services in higher cost settings such as hospitals, and getting 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 as 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.

Integrated or accountable care and the NHS

In April 2014 Simon Stevens was appointed Chief Executive Officer for NHS England (NHSE), just six months before it published its Five Year Forward View (5YFV). This echoed many of the WEF’s proposals and argued the need for “radical new care delivery options” for the NHS, such as the Multispecialty Community Provider’ (MCP) and ‘Primary and Acute Care Systems’ (PACS). These new models of care bring together different services (such as GP, hospital specialist and social care services)  in one system in a way that NHSE says is similar to the Accountable Care Organisations (ACOs) found in countries such as Spain and the US.

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, paying CEOs exorbitant salaries, if not engaging in systematic fraud. ACOs were introduced to reduce spending while improving quality measures. They also shift risk from payers (e.g. insurance companies) to service providers who are paid to manage the health of populations rather than the quantity of services provided.

Within two years of publishing FYFV, NHSE divided England into 44 new local health systems (‘footprints’), each of which had to produce a Sustainability and Transformation Plan (STP) to show how it would transform services in its area, in line with NHSE’s 5YFV. In 2017 NHSE announced that each ‘footprint’ would became a Sustainability and Transformation Partnership (ST Partnership), the vehicle for introducing ‘integrated’ or what is also called accountable care.  NHSE’s ambition is for ST Partnerships themselves to become full-blown Accountable Care Organisations (ACOs), but given the complexity of this process, ST Partnerships are initially expected to evolve into Accountable Care Systems (ACSs).

These models of care will be financed by new capitated payment arrangements, such as ‘a whole population budget’ (a fixed payment to provide specified services for a defined, geographical population, for a set period of time). This type of payment system – especially in the absence of adequate funding, and even with minimum standards in place –  provides an incentive to raise the level at which treatment is offered in order to minimise costs, regardless of the care that is needed. 

There is concern that restructuring the NHS through these new models of care could facilitate a shift in the fundamental nature of the NHS, away from a public service that covers the cost of treating all medical problems towards a privatised system. With the NHS carved up into more manageable local systems (ACOs) with budgets large enough to attract private investors, it’s already the case that companies such as Centene are increasingly involved running these new systems, e.g. becoming ‘lead providers’. (In this context, a lead provider is an organisation, or consortium, that has a single contract to set up and manage an ACO, making decisions on the nature and location of services, for example, and sub-contracting with other providers as necessary.)

This type of system fits with a growing number of calls from some quarters for NHS treatment to be financed by private health insurance. For example, before the 2015 general election, the various political parties spoke of their commitment to a tax-funded NHS. But a couple of months later, a debate in the House of Lords on the sustainability of the NHS cast doubt on these assurances with, for example, suggestions that the government should ‘help the public to think of other ways to pay for healthcare”, whether this was through compulsory insurance or certain charges. (See also our pages on A Long Term Plan and Sustainability.)

This latest transformation of the NHS is ostensiblybased on the need to integrate services, including the integration of health and social care services. Currently, NHS care is paid for by taxes and provides care according to need while social care is means tested. It’s possible – especially given severe cuts in funding for local authorities – that the possible benefits of ‘integrating’ health and social care will be used as a justification for extending means testing or introducing some other form of charging for NHS care.

In February 2017, the National Audit Office (NAO) produced a report warning that progress with integrating health and social care has, so far, been slower and less successful than imagined, and that it had not brought the expected benefits for patients, the NHS or local authorities. It suggests that the government’s plan for integrated health and social care services across England by 2020 is at significant risk.

The NAO’s report also found that NHS England’s ambition to save £900 million through introducing new care models may be optimistic. The new care 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 page on the implications of accountable care systems.) 

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/

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 December  2017

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