Last month, Allyson Pollock warned in an article for the New Statesman that the development of accountable care organisations represents an attack on the fundamental principles of the NHS. Hers is one of a number of voices arguing that accountable care will result in private companies playing a bigger part in running NHS services and is occurring without proper public and parliamentary debate.
The reality is rather different and more prosaic. The areas of England leading the development of accountable care are doing so in response to the huge pressures on the NHS. Hospitals in particular are struggling to cope with growing numbers of people with complex needs presenting at A&E departments. Senior doctors have stated that patients are dying unnecessarily as staff try to manage ever growing workloads.
The NHS requires more money and staff to avoid a recurrence of this winter’s crisis but it must also redouble efforts to put in place new care models better suited to the population’s changing needs. It is this that lies behind the interest in accountable care, rather than a hidden agenda to privatise service provision.
Areas as diverse as Cumbria, Frimley, Nottingham, Northumbria, and Salford are pioneering new forms of “accountable care” in which health and care services work together to provide more services in people’s homes and the community. Early evidence collected by NHS England shows that these areas have started to buck the long term trend of rising demand for hospital care. This holds out hope that new ways of delivering care will bring benefits for patients and staff.
Why then has accountable care got a bad name? One reason is that the language of accountable care originates in the United States, and carries connotations of the excesses and inequities of that country’s health care system. Another is that NHS England has proposed a new contract for accountable care organisations that could be used by NHS commissioners wishing to develop accountable care by testing the market in a competitive procurement.
Campaigners opposed to accountable care have launched two judicial reviews of the proposed contract. Their main concern is that private companies could compete successfully to take on the contract and that doing so would run counter to the core values of the NHS. The collapse of Carillion has reinforced this concern by illustrating to the public sector the risks of outsourcing services for those who rely on them.
Recognising the reality of these risks, it would be wrong to extrapolate from the experience of the United States to the NHS. The context here is very different with the commitment to a universal and comprehensive health care system available on the basis of need and not ability to pay as strong as ever. There is no prospect that these principles will be compromised by the development of accountable care which is about how services are provided and not how they are funded.
Even if private companies do compete to provide services under the proposed contract, it is highly doubtful that they will able to generate profits in an increasingly cash strapped NHS. The withdrawal of the private health care company, Circle, from a contract to run Hinchingbrooke Hospital in Cambridgeshire in 2015 because of inadequate funding was a straw in the wind. With many NHS providers running deficits, it is unlikely that private companies will see the NHS as an attractive market to enter.
In any case, areas that are pioneering the development of accountable care have found ways of making progress without the need to use NHS England’s proposed contract. These areas are looking to NHS providers to take the lead in bringing together health and care services into integrated care partnerships. Different services are involved in different areas and they may include hospitals, community health services, mental health services, GPs and adult social care provided by local authorities.
Salford is a leading example. The hospital trust, which also runs community services in the area, is working closely with mental health services and local GPs. The city council has agreed that the trust should take responsibility for the provision of adult social care. The NHS is collaborating with the council to commission these services jointly in order to support the integration of care.
A similar example can be found in Mid Nottinghamshire, where an alliance of care providers and commissioners from the NHS and local government are working to integrate services for a population of 330,000. Integrated teams comprising GPs, specialist nurses, social workers and others have been established to provide joined up care to patients at high risk of being admitted to hospital. This has already helped to reduce the demand on the local hospital, as more care is delivered in peoples’ homes and community settings.
These public sector partnerships and many others like them are based on collaboration and not competition. They represent a shift away from the market-based reforms that have dominated health policy since the early 1990s and, ironically, are moving the NHS in the direction that those campaigning against accountable care have often argued for. The prospect is of services coming together to meet the needs of local people with a much stronger emphasis on collaboration instead of competition between NHS organisations.
NHS England has now announced that it will undertake a public consultation and has agreed to delay the use of the contract until the end of 2018 at the earliest. The House of Commons Health Committee is also about to embark on an inquiry which will explore the concerns of campaigners as well as the experience of those already working to make accountable care happen.
These are welcome moves that should enable a more measured debate to occur based on innovations showing that how the NHS and its partners can improve health and care for the populations they serve. NHS England should also change the language from accountable care to integrated care to more accurately reflect its intentions in promoting these new care models.
Chris Ham is CEO of The King’s Fund.
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