Despite massive re-organisation of the NHS as a result of the Health and Social Care Act of 2012 (HSCA), more radical change is now taking place, providing a further step towards privatisation as well as the means to implement cuts.
The latest restructuring is based on the benign-sounding idea of ‘integrated care’. But this is not integrated care in the sense of joined up care that’s carefully planned around individual patients. Instead its about a group of service providers (and maybe commissioners) combining to provide almost all services for a defined population.
The emergence of this kind of integrated care can be traced to the World Economic Forum (WEF), which describes itself as the International Organisation for Public-Private Cooperation, “providing a platform for the world’s leading 1,000 companies to shape a better future.” In 2012 the WEF carried out a project looking at the financial sustainability of national health services due to factors like “the growing burden of chronic disease” and “raised patient expectations”. The project lead was Simon Stevens, then Vice President of the United Health group (a transnational corporation based in the USA), and its report was co-authored by McKinsey (a global management consultancy firm also involved in drawing up the HSCA of 2012).
The preferred strategy put forward by the WEF report was to deliver more services with fewer resources, primarily by shifting health systems towards ‘integrated care’ – in effect reinventing the delivery of health care by introducing models of care that ‘manage demand’ more effectively and eliminate inefficiencies and waste. This strategy now informs the approach of NHS England (NHSE).
NHSE’s The Five Year Forward View and new models of care
Simon Stevens moved from United Health to become Chief Executive Officer of NHSE in April 2014, just six months before it published its Five Year Forward View (5YFV). This document promoted integrated care, describing how the delivery of NHS services was to be completely and rapidly redesigned through new models of care that dismantled traditional organisational boundaries – such as those between the NHS and social care, or between community care and hospital services.
The main models of care outlined were:
- The Multispecialty Community Provider (MCP) model, in which GPs and other community based health practitioners (e.g. district nurses, pharmacists) form an organisation that provides most out-of-hospital care for a registered list of patients, with a delegated responsibility for managing the health service budget for their registered patients. This would bring so-called ‘horizontal’ integration.
- The Primary and Acute Care System (PACS), where a single organisation provides GP and hospital services, together with – for example – mental health and community care. These were described as similar to the Accountable Care Organisations seen in other countries like the USA.
These models of care were supposed to provide a way of improving quality while cutting costs ( although evidence is mixed from the USA about the impact of ACOs on quality and cost). Both MCPs and PACs were to be funded by a ‘whole population budget’. This is a fixed or lump sum that will be paid to providers to cover the cost of almost all healthcare services for a defined population, over a set period (probably 10-15 years), irrespective of the care that is actually needed or provided: treatments will be limited to what is affordable within the budget.
The first step towards implementing the redesign of the NHS was taken in 2015 with NHSE selecting 50 pilot or ‘vanguard’ sites to introduce the new care models programme. Then, at the beginning of 2016, before these vanguard sites were fully up and running – and certainly before any evaluation had been done – NHSE produced a new directive. Called “Delivering the Forward View: NHS planning guidance 2016/17 – 2020/21“, it required the creation of new local health systems, each of which would develop a Sustainability and Transformation Plan (STP) that would put the FYFV into practice.
New local health systems or ‘footprints’
The directive Delivering the Forward View – for which NHS England has no legal authority – required the setting up of 44 new ‘local health systems’ or ‘footprints’ across England in what it called ‘place-based planning’ (i.e planning to cover an entire health area rather than a single organisation). ‘Footprints’ were to bring together ‘clinicians, patients, carers, citizens, and local community partners (including the independent and voluntary sectors), and local government through health and wellbeing boards. These new local health systems – the boundaries of which may roughly mirror those of county boundaries – are expected to transform the way that health and care services are planned and delivered for local people. The populations that they will cover range from 300,000 (for example in West, North and East Cumbria) to nearly three million people (as in Greater Manchester). On average they will incorporate three or four local councils and about five Clinical Commissioning Groups (CCGs). But ‘local health systems’ will not be responsible for all planning eventualities and it is recognised that different footprints will have different needs.
These ‘footprints’ share some similarities with the old Strategic Health Authorities (SHAs) that were abolished by the Health and Social Care Act (2012) although SHAs were not expected to make financial savings. Now, cutting costs is the first priority.
A further difference is that, unlike SHAs, ‘footprints’ have no statutory basis or accountability and so are not subject to the same level of scrutiny.
At the time of publishing Delivering the Forward View, there were no legal or other structures that connected the organisations or people involved, no procedures for dealing with disagreements, and little planning expertise among those expected to meet NHS England’s demands (expensive consultancy firms had a field day). And although NHS England could compel health care organisations to comply with their requirements, this was not the case for those bodies responsible for social care – local councils – that were also part of ‘footprints’.
Even so, each ‘footprint’ was asked to produce – with scant notice – a five-year Sustainability and Transformation Plan (STP), showing how local health and social care services will become financially ‘sustainable’ and transformed in line with the Five Year Forward View by 2021.
Sustainability and Transformation Plans (STPs)
In response to Delivering the Forward View, ‘footprints’ were to draw up their draft STPs with considerable secrecy: they were told by NHS England that they could not make their plans public. As NHS England’s Director of Commissioning Operations for North Midlands is reported as saying
Nonetheless, despite the secrecy, a number of STPs were leaked or some details became known through Freedom of Information requests. Then, eventually (December 2016), each footprint’s draft STP was published (see https://www.england.nhs.uk/stps/view-stps/), although not necessarily with the relevant appendices giving the important financial details. (These details, when available, were usually pretty impenetrable.)
STPs have to cover all areas of activity currently commissioned by CCGs and NHS England, including specialised services and primary medical care. They also have to ensure better integration with local authority services, including prevention and social care – and who would argue with that? But at heart, STPs have to:
1. Improve sustainability by achieving financial balance: Each ‘footprint’ is expected to cut expenditure and stay within budget through, for example,
1. Improve sustainability by achieving financial balance:
Each ‘footprint’ is expected to cut expenditure and stay within budget through, for example,
‘Delivering the Forward View‘ argues that “local NHS systems will only become sustainable if they accelerate their work on prevention and care design”, including the implementation of the new models that increase out-of-hospital care proposed by the FYFV.
Of these priorities, plans for ‘sustainability’ are given the most weight: Of the £1.8 billion earmarked for STPs for 2016/17, a total of £1.6 billion was to be made available to those ‘footprints’ whose plans met the financial control targets agreed with NHS England. In contrast, just £200 million was available for plans to improve efficiency, such as the introduction of new models of care.
Overall, STPs were to become the single application and approval process by which cash-strapped ‘footprints’ would have access to ‘transformation funding’ from 2017/18 onwards. But if an STP failed to show sufficient ‘financial discipline’, not only would the ‘footprin’ be denied access to this funding, it could be put in special measures and have its leaders replaced.
STPs were also to be assessed on additional measures besides finance, such as
- whether they will expand the use of integrated personal budgets (especially for maternity, end-of-life and elective care);
- whether they support the national roll out of the Healthy NHS programme to improve the health of the ‘footprint’s’ workforce; and
- how they will facilitate the implementation of ‘seven day’ services.
iii) Lack of legitimacy
Until recently, the nature and extent of changes that STPs were to bring about would have had been introduced or supported by government white papers, formal public consultation, policy guidance, primary legislation and statutory instruments. In contrast, the transformation of the NHS that STPs and the new care models programme they introduce are only by order of the Chief Executive of NHS England.
What’s more, some of the changes being introduced are at odds with existing legislation:
On top of which, the development of each STP was led by an ad hoc group of people drawn, for example, from CCGs, health service providers and local authorities: as an organisational body, the ‘footprint’ has no formal existence, no legal authority. Nonetheless, NHS England (itself not a statutory body) expects them to impose decisions on organisations that do have statutory authority and accountability (such as CCGs and local authorities). For example, in March 2017 Simon Stevens (Chief Executive of NHSE) told the House of Commons Public Accounts Committee that
We are going to formally appoint leads to the 44 [Sustainability and Transformation Partnerships]. We are going to give them a range of governance rights over the organisations that are within their geographical areas, including the ability to marshal the forces of the CCGs and the local NHS England staff.
In addition, as non-statutory bodies, the new ST Partnerships are not required to undergo internal or external audit. Consequently,
Decision-making is likely to become less transparent. Public consultations, board meetings and formal, open ways to make decisions and to challenge them are likely to be replaced or subverted by backroom deals and horse-trading. (http://blog.policy.manchester.ac.uk/posts/2016/09/the-nhs-reform-reorganisation-and-the-risks-of-rushing-into-changes-without-proper-scrutiny/)
iv) Lack of public involvement and consultation
NHS England, CCGs, NHS foundation trusts and NHS trusts are all under a duty to make arrangements to involve patients in:
- the planning of commissioning arrangements (NHS England & CCGs) or provision of services (NHS foundation trusts and NHS trusts);
- the development and consideration of proposals for changes in the way those services are commissioned/provided which would have an impact upon the range of services available or the manner of their delivery; and
- decisions affecting the operation of those commissioning arrangements/services which would have such an impact.
However, patient involvement in the development of STPs before their submission to NHS England was minimal (see our page on Patient engagement and consultation) In addition, STPs were not developed by CCGs, local authorities or other bodies that are under statutory requirements to consult, but by a new organisational form – a ‘footprint’ – that had no formal existence. This means that their obligations and accountability are unclear.
iv) Lack of financial credibility
There are growing doubts about the credibility of STPs as cost saving measures. A review of the 44 ‘footprints’ by the British Medical Association found the claim that STPs would save £26 billion from NHS and social care budgets to be unrealistic:
- most savings depend on the injection of capital up front in order to update or build new health facilities – but this money is not available. It’s estimated that, collectively, ‘footprints’ will need £9.5 billion of capital funding to create the infrastructure necessary to deliver the STPs;
- In the UK there is virtually no evidence to suggest that the large scale reshaping of hospital services will improve NHS finances;
- Although most STPs claim that they can cut costs by moving services out of hospitals, research suggests otherwise, especially within five years;
- to be in line with NHS England’s five year plan, public health and prevention have to be priorities for STPs. However public health and prevention are now the responsibility of local authorities, whose budgets have been seriously cut in recent years;
- it’s expected that savings can be made by providing more care in the community, but many STPs don’t consider where funding for extra work in the community will come from.
In addition, the many STPs have been drawn up in large part (and presumably in their own interests) by private consultancy firms like PwC, with ‘footprints’ each shelling out millions of pounds for their services.
Accountable care systems and accountable care organisations
Subsequently, Next Steps on the Five Year Forward View (NS5YFV), published by NHSE in March 2017, required ‘footprints’/STPs to morph into Sustainability and Transformation Partnerships (ST Partnerships) to implement the STPs and create integrated (or accountable) care systems.
As with ‘footprints’, these Partnerships have no statutory basis: according to the NS5YFV, they “supplement rather than replace the accountabilities of individual organisations”. How they work will vary across the country – although the government’s preferred ways of integrating services is first through ST Partnerships evolving into accountable care systems (ACSs), with some of these eventually becoming accountable care organisations (ACOs).
In essence, while ACSs can take many different forms, what they have in common is a defined population, a uniform payment system and a focus on health outcomes. NHSE describes an ACS as a locally integrated health system (possibly a part of a ‘footprint’), within which NHS organisations – often in partnership with local authorities – take on collective responsibility for the health of a defined population and the resources to deliver care services, while making savings – for example by targeting patients at risk of avoidable hospital admission. An ACS is expected share savings, as well as risk and any losses, across the system.
ACSs are expected to have more control over the operation of the health system in their area. They are part of a more general shift required by NHSE towards ‘demand management’. This means creating a health service that operates on a fixed budget (based on a set amount per head of the population in a defined area) and controls access to services by limiting treatments to what ‘affordable’ within this budget. This approach runs counter to the basic principle of the NHS – to provide appropriate treatment to all, based on clinical need.
In June 2017, Jeremy Hunt had announced the first eight ‘shadow’ ACSs, as a step towards more integrated care. The eight pioneer ASCs will have to determine what accountable care means for them and shape it out of existing independent organisations (https://www.hsj.co.uk/sectors/commissioning/the-commissioner-next-steps-for-stps-part-1-towards-accountable-care/7016284.article) They will be expected to take the strain off A&E departments, invest in general practice and improve access to quality cancer and mental health services. They have, in principle, agreed a draft Memorandum of Understanding (MOU) with NHSE that will, among other things, sign them up to
- reducing the growth of use of NHS services, and
- achieving a single financial control system – something the MOU acknowledges will “inevitably be bumpy in terms of its impact on the financial position of individual organisations”.
According to the British Medical Association, the main difference between an ACS and an ACO is that, with ACOs, there is a single contract with a single provider that will make most of the decisions about how to allocate resources and design care for its local population, including decisions on changing the method or point of service delivery. This single provider could be an NHS organisation or a private company that may sub-contract other providers. Both sit outside current legislation. With both ACSs and ACOs, individual health care organisations within the scheme are asked to set aside their own interests for the good of a wider system. This may prove difficult, especially as some providers within the system will be private companies whose agenda will be incompatible with this approach. There are also indications that ACOs have found it difficult to develop governance arrangements that are able to hold their partners to account as a collective.
A major element of NHSE’s FYFV is the increased use of IT – e.g. to prevent admissions and support out of hospital care. And both ACSs and ACOs are heavily dependent on software and information technology, for example to store patients’ records, enable the sharing of patients’ data across health care systems, or collect data relating to treatment costs and revenue margins etc. Recent research on ACOs in the USA has found that over $100 billion has been spent on such technology over six years, without any notable return on investment: there is no change in the quality of care or the cost of care that the ACOs provide. Physicians are also increasingly dissatisfied with the software they have to use to support safe, evidence based care. Apparently, one-third of the organisations in a Pioneer ACO Program in the USA are dropping out because, despite their investments in software and information technologies, they are unable to quantify the quality of care and financial risk for managing patients in the ACO.
For more information, see our page on ACOs.