Written for the membership of the National Pensioners Convention Health and Care autumn Newsletter, so for potentially a relatively non expert audience (but quite a few are real experts and very engaged and passionate).  It refers to an Americanised system – the current direction of travel under the government.

Accountable Care Organisations (ACOs) are surprisingly upfront about their aims, ambitions and raisons d’etre. The US frontrunner amongst ACO’s, Kaiser Permanente, emphasises the importance of bonuses, asserting that providers will make more money if they keep patients healthy. That might look reasonable until we think a bit more deeply about what it could mean; if a doctor gets more money if his patients are well, then the temptation is to maintain a list of healthy people as far as possible. In days of rising health inequality, we are talking about health organisations set up to cater to the middle classes – people who can evaluate health evidence, and have the means to follow a good diet, exercise, and be less burdened with severe income issues. The poor are likelier to adopt unhealthy lifestyles, including drink and drugs, as a means of coping, a way of shutting out the unfairness of society. They are not a source of profit. Healthcare then becomes biased to meeting the wants of the fit, young, healthy and monied, increasing the disadvantage of the poor, disabled, sick and elderly. This approach becomes normalised, and where it is questioned we have the narrative on deserving and undeserving patients to quiet our bad consciences.

Our medical professionals went into the NHS for good, caring reasons. Surely, they will not adopt this ethos? Even good people can run with the wrong ideas. The deaths of babies, especially at Morecambe bay hospital were partly attributed to a decades long campaign on natural childbirth. Somehow abandoning common sense and patient safety, midwives sincerely believed they were processing the dictated agenda – an agenda which took precedence over all other concerns and issues. Where it is so easy to prioritise agendas over people we cannot assume the Accountable Care agenda will not undermine and subsume free at the point of use cradle to grave care for all the idea on which Bevan founded the NHS.

America has been favouring, by law, the Accountable Care type organisation simply because it claims to save money. ACOs make providers jointly accountable, and save money by avoiding tests and procedures. Of course, nobody wants unnecessary tests and procedures, but the money saved by ACO’s they can keep. Again, the temptation to put money before patient’s interests. In addition, if they take on more financial risks they get to pocket even more. It is so easy to see how the model will corrupt the co-operative ethos of the NHS, and lead inexorably to co-payments and insurance schemes, which are in nobody’s interests but the very rich, as the US model, the worst in the developed world, shows.

ACOs can be set up by anyone. A foreign owned supermarket chain just needs to employ a GP. Even worse, health insurers can become ACO’s, and have access to and oversee, patient data. That would seem a conflict of interests, since they could identify “expensive” or rather what we call sick, patients on their lists. The US trend is to merge forming Super-ACO’s dominating or more likely the sole providers of all healthcare in an area. Where do you go when you are not able to get on a list due to being identified as “too sick” by the conjoined ACOs in your area? Remember we no longer have a Government with a duty to provide healthcare to the nation.

They are, so we are told, a way of delivering coordinated care which must be a plus as healthcare is becoming increasingly fragmented? Not so much when the underlying driver is to save, even at the expense of the patient. My GP currently coordinates my care and the idea would be even better in a coordinated and co-operating properly funded NHS. Despite all this, ACOs are not the worst manifestation of the US healthcare system. They admit the American system is broken and know they are a flawed model. They hope their model will lead to a more efficient and sustainable system – not unlike our NHS before our government listened to American lobbyists and decided that their inferior model was the way for England to go. Interestingly the US experts see it as one rung up on the way to a system like ours. ACO’s, for us in England, are a downgrade from our current models, and a Trojan Horse to even greater degradation of our beloved system.

Yes, it will get worse. Many people, though fewer now, repeat that they don’t care if it is free. I think I have illustrated that ACO’s are a model which will sooner or later lead to payments, insurances and rationing…disadvantaging the older and poorer sections of society. There are already people questioning just how dedicated the system is to keeping older people alive, and operations and procedures like hip and knee replacements are becoming a postcode lottery. Try to go private and you will see the real costs. Our NHS is no longer always free, even if you have the health need. Older people in general, and particularly the frail elderly are seen less as people, more as a drain of the system under this ideology. There is little profit to be made. The insurance industry is already eyeing up the gap, as anyone who uses a computer regularly can testify. Giant insurance corporations are major players in the ACO story. The young and healthy are where the money is for them.

In years to come we may well be offered initially the Trojan horse of a “soft” version of insurance, and breathe a sigh of relief. Do not be fooled. In the USA the combination is toxic, with both the provider of healthcare and the provider of insurance joining to deny treatment for the sick, and even shockingly the dying. A US colleague with Rheumatoid Arthritis, who then got breast cancer was made homeless by her healthcare requirements costs, and then denied lifesaving surgery. A compassionate academic, she was “deserving” in anyone’s’ book, but that is what this system boils down to. All of us will be depersonalised sources of profit. There will, in reality, be no deserving and undeserving categories. It will all be about profit – as the law says it must.

To be fair another colleague didn’t have such a bad experience with Kaiser, but she was a very well insured ex-public-sector worker. She likes the “joined up” system. She thought it the best of the best, and it does have a good point in ensuring all the specialists talk to each other, which we could easily emulate in the NHS, and sometimes do – though privatisation and commercial confidentiality is eroding this fast. We can look at any good bits, but we do not need or want the system as a whole.

In the UK, especially, but not only, in England, I see the ACO system as an enabler of “localism”. By localism, I mean in the Tory sense in which power and funding is centralised, while localities bear the brunt of withholding of funds and poor decision making centrally, and are forced to take the blame. The public do not get to hear about the orders from above, but understand the consequences all too well. Disobey such orders? No funding, or much less funding, and the local people and patients are punished even more harshly. Initially well-funded ACO’s may look good at first, as long as you are not living with a chronic condition, are disabled, or elderly, but at some point, the money to support trickles to a near halt under this government, and this funding gap, and any private debts required for new builds, will hit. We need only look at the current care system to know just how bad an underfunded system driven by the private sector can get. There are, so we are told, going to be a lot fewer of them (ACOs) than our current hospital system. Imagine travelling past your local hospital, now a housing estate, then travelling on our congested roads for miles to get to your nearest ACO in an emergency. I cannot believe that in such cases our chances of survival would be enhanced. I can easily see the scenario would kill. Think of those mums encouraged into home births, needing a hospital procedure urgently for example.

Some might be thinking, though they may not want to say it out loud, do the Americans “like me”, and paying,  get more bang for their bucks? I have worked with the system for more than a decade, and have a one word response. “no”. I know of people travelling a hundred miles to see a specialist, only to get there and find the appointment has been cancelled. Waits of months for a GP appointment. Overworked and indifferent GPs – much worse than the NHS, except with an eye wateringly hefty bill. Even their co-payments sound terrifying to me. There are many demoralised doctors  working in a demoralising system, with a few benefiting greatly if they play the game.

STPs have gone quiet (for the moment), and now it is all about ACO’s. Just how does everything fit in the new proposed system? More to come!!!

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  1. Eric Leach says:

    Interesting piece. Some comments:

    + There are quite a few old(er) people in London who have money (possibly tied up in their home). The one off, unprecedented increase in property values along with free good quality University and Polytechnic education, decent corporate pensions in the 60s and 70s leading to finding well paid jobs.

    + Oh dear – localism. As Chair of my local Neighbourhood Forum I know only too well that the small print of the 2011 Localism Act gives all the ‘final says’ to Local Authorities (LA). Non-co-operating LAs (and there are plenty in London) kill off local citizens’ efforts.

    + None of the ACO case studies I have read about in the US, Sweden, Spain and New Zealand have managed, in five years, to cuts costs by 20% integrate healthcare and social care and measurably improved care outcomes. Surely this is how the Hunt/Stevens STP/ACS dream could fail and the FYFV be discredited, and inevitably atrophy..

  2. Anonymous says:

    ACOs are a blind alley.
    They seek to reproduce the american healthcare system but the flaws in any membership scheme are what happens to those not members. Our population is too mobile to make a capitation based system robust and costs and geography to uneven to make a standard tariff based system just.
    All of the efficiency gains from the model are based on the assumption that patients are overtreated. Which they are in the US but not in the UK.
    The more interesting question is whether european style healthcare systems based on the contributory principle , basic rights to healthcare and modest co-payments with high levels of protection for the elderly and poor is not a better way of ensuring adequate resources, higher standards of care and a more responsive system geared to meeting needs.
    The evidence is that it does. Which is inconvenient for lovers of the NHS.

    1. lallygag26 says:

      I have lived in France and have direct experience of its healthcare system. It does not always care well for those in rural areas who may have to travel up to 100kms to receive hospital treatment. It does not always care well for the uninsured who are in receipt of public assistance. Some of its hospitals are, frankly, in a dilapidated and disgusting state and public hospitals can be decidedly second class with low paid and unqualified staff filling gaps where nurses ought to be.

      I also have French friends who panicked when the sole earner in the household, after a lifetime with the same company and close to retirement was made redundant. Her biggest worry, after the shortfall in her pensionable years? That she would no longer have a good ‘mutelle’ – the co-payments which had given her and her partner very good health cover. They were both very anxious about the possibility of being reduced to state provision – the cheapest, lowest quality for everything.

      I have seen enough to be convinced that any system that says you can pay varying contributions into different co-payment or insurance systems to ‘top-up’ state provision, with those in financial need covered in full by the state, will inevitably provide a service which is tiered according to your personal contribution. The poor will always be on the bottom tier.

      I prefer the principles of the NHS. I would like to see commercialisation and privatisation removed and the system re-vamped to make its principle of equality of high quality provision for all a reality. It could if the political will was there to make it so.

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