As little as five years since the massive restructuring imposed by the Health and Social Care Act (HSC Act) of 2012, the NHS is again undergoing radical change, this time at reckless speed and without public or parliamentary consent.
Recent changes by NHS England (NHSE) divided the English NHS into 44 local health systems or ‘footprints’ (now ‘Sustainability and Transformation Partnerships’ or STPs). Each of these is required to integrate its local health and social care services through cross-boundary working and pooled budgets.
These changes, relying on collaboration between healthcare providers within a ‘footprint’, currently run counter to the Health and Social Care Act of 2012, which sought to increase competition.
Now, further developments in 2017 mean that STPs are required to deliver ‘accountable care’ by morphing into Accountable Care Systems (ACSs), with the aim of eventually becoming Accountable Care Organisations (ACOs). ACOs are non-NHS bodies, ‘designated’ by NHSE, despite the absence of any statutory authority.1 Behind the rhetoric of replacing competition with collaboration, NHSE intends to substitute the current system of procurement with one inviting tenders for a single, long-term lead ACO contractor for each region, empowered to decide both the location and nature of services.
These developments are influenced by thinking from the World Economic Forum (WEF) that favours governments cutting back on public services and giving corporations a greater role. The WEF argues that the costs of national health systems like the NHS can be reduced by introducing new models of care – accountable care systems – that ‘integrate’ services, reduce hospital capacity and expect individuals to provide more ‘self-care’.
NHSE argues that introducing ‘accountable’ or ‘integrated’ care is central to Government aims for the ‘financial sustainability’ of the NHS. In this context, ‘sustainability’ means reducing services to match insufficient funding. Despite being one of the richest countries in the EU, GDP spending on health care per person in the UK is below EU-15 average.2
Accountable care systems (i.e. both ACOs and ACSs) need to be opposed for the following reasons:
- They are being introduced without adequate public involvement or meaningful consultation, and without Parliamentary scrutiny;
- They are being imposed in a context where NHS and social care services are seriously underfunded;
- They are being implemented beyond any legal framework, creating problems of governance and accountability;
- They are being introduced at reckless speed, with no robust evidence base to support their use in the UK context;
They increase the potential scope of NHS privatisation by new procurement arrangements that may prove attractive to multinational corporations: ACOs will have a single, long-term contract to commission and provide health (and possibly social care) services for an entire region.3
ACOs will help strip NHS assets, such as land and buildings, allowing private companies to profiteer while ending the social ownership of much of the NHS estate.
While NHS costs will continue to rise by around £22 billion by 2020 (compared with 2015 levels),4 ACOs and ACSs will enforce an unprecedented real terms freeze in spending. They will transfer the NHS’s funding shortfall to new local, self-contained areas and, as a consequence, they will compound health inequalities and regional variation in health provision.
New payment systems will incentivise rationing of services and denial of care, and so are fundamentally at odds with social solidarity and the values of equity and universalism that underpin the NHS;
They rely on unrealistic expectations, for example about collaboration and the sharing of risk and gain between private and NHS service providers.
They rely on ‘transforming’ the NHS workforce, replacing experienced clinicians such as doctors and nurses with technologies, while introducing new, lower skilled roles, such as physician and nurse associates. ACOs are likely to under- deliver required skill levels and undermine NHS terms and conditions of employment.
need to be better coordinated. However, this does not require commercial contracts and the involvement of corporations.
can deny that acute, primary care and community NHS services and social care
A truly coordinated system of health and social care requires:
- a) Increased funding of the NHS and personal social care;
- b) Personal social care provided on the same terms as health, free at the point of use and paid for from public funding;
- c) Full public involvement and meaningful consultation;
- d) Robust piloting of future plans for co-ordination and in-depth, independent evaluation; and
- e) New legislation (see, for example, the NHS Bill 2016-17) that protects Bevan’s founding principles of the NHS; ends the marketisation and fragmentation of the NHS; and re-establishes public bodies and NHS services that are accountable to Parliament and local communities.
See https://keepournhspublic.com/resources/resource-cabinet/ (Accountable Care Organisations and Systems) for more information
4There have not been actual cuts in total NHS funding since 2010 – funding has risen very slightly in cash terms. However, the rise has been far slower than the growth of population need and cost pressures. £22bn is the gap between the virtually frozen funding for 2015-2020 and the steadily rising costs and pressures, and that implies “savings” which must amount to cuts.