Category Archives: Accountability

Staff at Frimley Health NHS Foundation Trust, who face being transferred to a wholly owned subsidiary (WOS) designed to avoid paying tax, will strike in protest for a further three days this month.

Unite, Britain and Ireland’s largest union, said today (Thursday 5 December ) that its estates’ management, equipment maintenance, catering, portering, procurement and security staff, numbering about 90, will strike from 07.00 on Wednesday 18 December for 72 hours.

This latest wave of industrial action follows two days of strike action last month.

Unite will be coordinating  the strike action with the GMB union – altogether about 1,000 staff at Frimley Park Hospital, Camberley; Wexham Park Hospital, Slough; and Heatherwood Hospital, Ascot are affected by the trust’s plans.

Unite said that it had evidence that the trust is intent on pushing ahead with its flawed business model, as it is issuing new uniforms without the distinctive NHS logo on the clothing, which previously had been the case.

Unite regional officer Jesika Parmar said: “The latest bout of strike action this month demonstrates the continuing depth of anger at what we believe is biggest proposed wholly owned subsidiary in England so far, which could adversely affect up to a 1,000 employees at the trust.

“Our members have voted overwhelmingly that they have no wish to be employed by a WOS designed to avoid paying tax. They are concerned that their pay and employment conditions will be seriously eroded by such a plan.

“Already the trust is issuing new uniforms without the NHS logo on the clothing, which previously had been the case – it is clear that the trust bosses don’t see this new venture as being part of the NHS, which is disgraceful.

“The trust is also attempting to undermine the strike by employing expensive agency staff.

“We are calling on the trust’s board to ditch these misguided and flawed plans. We are seeking an undertaking from the trust that it will agree to continue to employ all our members and not transfer them to a WOS.

“We remain strongly against the formation of these entities which, we believe, could lead to a Pandora’s box of Carillion-type meltdowns – with knock-on effects for patient services and jobs.”

The Frimley trust provides NHS hospital services for about 900,000 people across Berkshire, Hampshire, Surrey and south Buckinghamshire. Unite has 220 members at the trust and only balloted those directly affected by the WOS.

Unite members voted by 92 per cent to strike.

Notes.

Unite has waged an extensive campaign against these wholly owned subsidiaries as they could lead to job losses and salami slicing of service provision.

Unite is concerned that trusts are forming these wholly owned subsidiary companies in England so that they can register for VAT exemption and compete on a level playing field with commercial competitors who register for VAT exemption for their work in the NHS, when NHS trusts can’t.

There were more than 30 such subsidiaries in England in 2018.

The Department of Health and Social Care announced last year that it was consulting on this issue. The consultation ended in November 2018 and the requirements that trusts and foundations have to meet to create wholly owned subsidiaries were tightened up.

This also included a condition to consult stakeholders, such as staff and the wider community. A number of trusts have already decided to abandon plans to set up such a subsidiary.

Email: shaun.noble@unitetheunion.org

Twitter: @unitetheunion Facebook: unitetheunion1 Web: unitetheunion.org

Unite is Britain and Ireland’s largest union with members working across all sectors of the economy. The general secretary is Len McCluskey.

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The title of the new GP contract is “ Investment and evolution: A five- year framework for GP contract reform to implement the NHS Long Term Plan.” 31.1.19 (Framework)

The main aim of NHS England’s ‘NHS Long Term Plan’ 7.1.19 (LTPlan) is to establish Integrated Care Systems (ICSs) throughout England by 2021. And for these to evolve into Integrated Care Providers (ICPs) (Ps 29 – 31 LTPlan) ICSs and ICPs were previously called Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs). It was against the latter that Judicial Reviews were fought by NHS campaigners from 2017.

In January 2018, Pollock & Roderick exposed the potential for single contract organization ACOs to be run by private companies to make profit out of commissioning and providing health and social care for large populations of NHS registered patients, on huge longterm contracts. (1.) The purpose of ICSs and ICPs it to totally transform 1) the payment systems and 2) the commissioning and delivery systems of health and social care in England, along the lines of US Accountable Care. (1.2.3.) In the latter, providers of healthcare are incentivized to work together, to commission and provide the vast majority of healthcare for a whole population, on a capitated budget. The commissioner and provider align objectives to make a surplus on the budget, whilst pledged to achieve quality standards.

The basic principle is that of American Health Maintenance Organisations (HMOs); “ the less care you provide, the more money you make.” Methods used to commission and provide care below budget are to; develop keen leaders, risk segment the population, sophisticated digital systems to promote virtual consultations, share patient data and collect data on health service use and cost, and ‘integrated Multidisciplinary teams” of mainly non-doctors adherent to managed care pathways providing 24 hour continuity of care to keep patients out of hospital substituting for doctors as often as possible. Ruthless imperatives are to *reduce ‘skill mix’, *continually redesign care to cheapen and cut it and *stop patients accessing hospital care.

The favoured payment systems are; a) capitated budgets ( whole Population budgets ) b) performance related rewards e.g QOF and CQUINs in England c) ‘Shared Savings Schemes’ All of the above characterize “ A new Service Model for the 21st Century” promoted in the LTPlan ( Chapters 1 &7) and the Framework.

But the confusing way they are written disguises the US style Accountable Care being smuggled in.

The reference to ICS boards on Page 30 LTPlan actually refers to the STP boards (Sustainability and Transformation Partnership boards) already imposed in 44 areas of England in 2016.
Their remit, known from STP plans, is to make huge cuts, reconfigure care out of District General Hospitals, develop a ‘local system workforce’ with ‘new roles’, divert elective care into the private sector and get GPs into ‘scale’ integrated primary care systems.
The barrier to the latter, despite all the super practices, federations and primary care networks that have been created in the last five years by NHSE, is the fear amongst GP principals that they would lose their independent NHS contractor status and their life long General Medical Services (GMS) contracts. This would be the case in ICPs.
GPs are right to be worried. The strategy is to ‘supercede’ so called ‘ cottage industry’ GP practices, with ‘post industrial’ care, through ‘family care networks’. (4) The Framework is being hailed as the solution. NHSE is happy that GPs are being herded into new Primary Care Networks ( PCNs ) enabling the establishment of ICSs, allover England by 2021. The BMA applauds the Framework as a victory for saving GPs’core primary medical services contracts for now.
But the title gives the game away. It is five-year GP contract reform “to implement the NHS Long Term plan.” GPs are being told to sign up to a Network Contract DES ( Directed Enhanced Services ) (5) as an “extension” to their core practice contract AND a Network Agreement, which is a legal integration agreement. “ The PCN is a foundation of all integrated care systems;…” ( P 30 p4.28 Framework)

The practices, in agreeing to the Network Contract DES, AND the Network Agreement are bound to work together, share patient and other data, carry out network specifications, share network funding for new non- doctor network staff ( >22,000 of them over 5 years ) and deliver other urgent care and extended hours services.
The network agreement requires that providers of other medical and social care, join the new PCN, e.g. community providers such as dentistry, optometry, Virgin run nursing, charities, acute and mental health trusts and local authority social care, over time. In this way the new PCN becomes an integration machine.

In signing the Network Contract and Network Agreement ( and agreeing an area covering 30 to 50,000 or more population, giving their patient list numbers, choosing a Clinical Director to sit on the Sustainability and Transformation (STP) board, and deciding which NHS contracted body will receive central network funds,) the member practices would form a new PCN.

Practices are being jumped into joining new PCNs by 30.6.19. Although this is supposed to be voluntary, pressure is being applied for 100% coverage.
The new PCNs would work under the direction of the STP via the Clinical Director and must deliver LTPlan and STP directives and protocols, i.e. commissioner diktats, or network funding stops.

In this way the STP in the area ( 1-2mn population) would become REAL.- in the sense of running GPs and patient lists as their delivery arm. ICSs = STP boards + PCNs. ICSs cannot function without NHS registered patient lists.
Astonishingly, whether practices join the new PCN or not, their patients will belong to the Network anyway (P 28. p 4.19) and network services would still be provided to those patients.

Two critical consequences flow from this Framework; 1. Patient lists will in future belong to the practice AND to the network.
The ownership of NHS patient lists will in this way be acquired by the ICSs. 2. GPs will be working to their original practice contracts AND to the Network contracts. The two contracts would be double running.
GPs are being assured that as they still retain their core practice contracts, – all be-it overlayed by the Network Contract DES, and the network integration agreement – that they are safe and their original GP primary medical services duties would remain the same.
But for those with eyes to see, -with the augmentation of network funds over five years, ( £1.8bn nationally compared to £1bn for the core practices ) the flooding -in of new non -doctor network staff to do GP work, requirements to perform new ways of working, and redesign care, and diktats to reduce hospital referrals and cut hospital care to achieve ‘shared savings’ for the ICS, – that GPs would lose their autonomous leadership role of patient advocate, prioritizing optimal care for their patients. GPs would find themselves driven by perverse incentives to endorse the constant cheapening of care and denial of hospital treatment.
GP practices would become entangled in the Networks physically and financially and find it difficult to get out again. They would be better to not sign up. Over half of GPs are now salaried sessional or locums and the BMA GP membership has not had a vote.
This Framework is a thousand times worse than the GP contract change in 2004. It aims to herd GP practices into new integrating networks which form the basis of giant ICSs throughout England. Through multiyear GP Network contract changes, the Framework enables ICSs to ‘evolve, and paves the way for fully integrated ICPs on single long term NHS contracts, tailor-made for international corporate takeover.
The American model has been pursued in England by successive governments since Enthoven recommended HMO Kaiser Permanente to Mrs Thatcher in 1990. Simon Stevens, (Blair’s health advisor 1997 – 2004, vice president of UnitedHealth the biggest US health insurance company 2004 – 2014) was appointed CE of NHSE in 2014 by David Cameron, and then advocated ACO style ‘new models of care’ in the Five Year Forward View. (6) American accountable care methods are now being imposed in England from within by NHSE, well before President Trump opened his mouth about more US trade deals.
These proposals should be exposed and opposed by all who treasure the NHS publicly provided according to clinical need, comprehensive and free at the point of use.

Anna Athow

annaathow@btinternet.com

9.6.19

references;

  1.  “ Why we should be concerned about accountable care organisations in England’s NHS.” 30.1.18 BMJ 2018; 360 doi: https//:doi.org/org/10.1136/bmj.k343
  2. UnitedHealth Center for Health Reform & Modernisation “ 2012FAREWELL TO FEE-FOR-SERVICE A “Real World “strategy for Health Care” Dec 2012: https://www.unitedhealthgroup.com/content/dam/UHG/PDF/2012/UNH-Working-Paper-8.pdf
  3. “Accountable Care’- the American import that’s the last thing England’s NHS needs.” Stewart Player, 1.3.16 https://www.opendemocracy.net/ournhs/stewart-player/accountable-care-american-import-thats-last-thing-englands-nhs-needs
  4. “Commissioning and funding general practice Making the case for family care networks.” 2014 Rachael Addicott & Chris.P 38 https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/co mmissioning-­‐and-­‐funding-­‐general-­‐practice-­‐kingsfund-­‐feb14.pdf
  5. “Network Contract Directed Enhanced Service” NHSE 29.3.19  https://www.england.nhs.uk/wp-­‐content/uploads/2019/03/network-­‐contract-­‐des-­‐specification-­‐2019-­‐20-­‐v1.pdf
  6. “The Multispecialty community provider ( MCP ) emergingcare model and contract framework” July 2016 Gateway 05637 https://www.england.nhs.uk/wp-­‐content/uploads/2016/12/1693_DraftMCP-­‐1a_A.pdf
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Background

The NHS Executive outlined eight groups of suggested legislative changes in the NHS Long Term Plan and, as promised in the Plan, these have now been set out in further detail in Implementing the NHS Long Term Plan: Proposals for possible changes to legislation [1]. The intention is to make it easier for NHS organisations to work together. Ostensibly these proposals are supposed to help the NHS improve its delivery of services but we see real problems here.

Principal objection

The Health and Social Care Act 2012 was a package promoting a range of checks and balances on the operation of the NHS, designed to support local commissioning; patient choice and competition at the provider level; governed by arm’s length regulators safeguarding quality and the NHS market; and local authority and consumer scrutiny, consent and supervision.

It is not easy to change one part of this without unravelling the whole but this is what is now proposed. There are good arguments for the complete revocation of this Act with its muddled thinking, naive faith in competition and GP-led commissioning, and the notion that politicians could shirk their own responsibility for taking difficult decisions by passing the buck to NHS managers and regulators.

But such a major change should only be done after full discussion, white papers, consultation and time to debate primary legislation in Parliament. These proposals are nothing more than a way of avoiding full Parliamentary discussion. The danger is that ad hoc tinkering rather than fully thought through reform will do more harm than good.

Lack of evidence

The supposedly new ethos promoted in these changes is ‘integration’ of service provision under one body. This may appear a plausible way forward but it is unproven as an operational principle or as a means of delivering improvements in efficiency or quality. The House of Commons Select Committee[2], the National Audit Office[3] and more recently the Nuffield Trust[4] have all produced highly critical reports of the new fashion for so-called integration. As yet these criticisms have not been answered.

A recent perplexed quote relating to the Greater Manchester (GM) experience sums matters up, “Everyone I’ve spoken to is at a loss to explain why GM’s performance has been so poor, given the progress that’s been made on integration and the transformation investment that’s gone in”, HSJ 25th February. The true lesson here is that integration does not guarantee success. But this is a lesson that NHS bosses do not want to hear.

We have closely monitored projects in various parts of the country that have been forced to pursue this transformation and integration agenda and, in for example Manchester where massive investment has taken place, there is precious little to show for it. The latest reports from the Nuffield Trust show that integration is a more costly model[5]. These proposals therefore lack evidence that the new policy response will succeed.

The downside of the proposals

All new proposals must demonstrate that they will do no harm. But, by making it easier to force mergers and close down acute hospitals in the name of ‘integrating’ services, the NHS is seeking to institutionalise a model that seeks to cut local services for patients without adequate consultation, and push back onto the patient the costs and delays of the failures of care that will result. At least checks and balances were built into the Health and Social Care Act 2012 requiring proper presentation of detailed plans, independent regulator support, widespread local stakeholder support and the right to challenge decisions; these would now be scrapped in favour of a centrally-led structure with NHS England at its heart, leading a purge of NHS capacity as it strives to meet government-imposed arbitrary financial targets.

These proposals are nothing more than a power grab by NHS England to enable its own transformation and integration policies to be imposed on unwilling communities. This is to be achieved by reducing the role of the independent regulators to mere ‘yes men’ as NHS England becomes the only source of power; by elevating the achievement of financial results to the overriding objective (best value); by being unaccountable to local people by removing the link to local accountability which however faulty was the basis for major decisions; and, by promoting a vague and meaningless slogan (integration) as the main principle justifying its activities.

Concluding remarks

This is a power grab by NHS England under cover of the distraction of Brexit to achieve for itself untrammelled power over the future of the NHS. It will then act quickly: a wave of mergers, closures and sub-contracting of new models of care would be unleashed. These changes would be enacted quickly and with very limited means for local people to challenge decisions.

MPs will find themselves and their constituents faced by a fait accompli with little that can be done. Voters in upcoming general and local elections will express their feelings for local hospitals in the traditional way (by voting against politicians who allowed this to happen). But it will be too late. Hospitals and A&E departments once closed rarely re-open. Services sub-contracted for 10-15 years or more will be difficult to restore. Huge integrated care organisations will be monopolistic in attitude and operation, and impossible to be held accountable effectively.

Local authorities will be either incorporated into this mess in return for crumbs off the NHS table, or left out in the cold while decisions take place around them that will push the costs and implications of changes onto patients and communities.

Oppose these changes to legislation. Integration is a smokescreen for NHS England to overrule local objections to service closures.

 

Roger Steer

14.3.2019

[1]

Implementing the NHS Long Term Plan: Proposals for possible changes to legislation

Engagement Document  February 2019 Prepared by: NHS England Strategy & Innovation Directorate and NHS Improvement Strategy Directorate

https://www.engage.england.nhs.uk/survey/nhs-long-term-plan-legislation/consult_view/

[2]

https://publications.parliament.uk/pa/cm201719/cmselect/cmhealth/650/650.pdf

[3]

Health and social care integration NAO February 2017

[4]

Shifting the balance of care Great expectations Nuffield Trust March 2017; and

Doomed to repeat? Lessons from the history of NHS reform  Nuffield Trust October 2018

[5]

https://www.nuffieldtrust.org.uk/research/age-uk-s-personalised-integrated-care-programme-evaluation-of-impact-on-hospital-activity

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The Pharmaceutical Journal reports that the Good Law Project threaten DHSC with legal challenge over “failure to consult properly”

From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

The Good Law Project has warned the Department of Health and Social Care that it will start judicial review proceedings if serious shortage protocol powers are not revoked on the grounds that the consultation was “insufficient and unlawful”.

A non-profit group has threatened the government with legal action unless it revokes new powers designed to allow pharmacists to switch patients’ medicines if there is a shortage.

The Good Law Project has said it will start judicial review proceedings over newly implemented “serious shortage protocol” powers if the Department of Health and Social Care (DHSC) fails to remove the amendments in legislation by 25 February 2019.

Amendments to the Human Medicines Regulation 2012, which came into force on 9 February 2019, mean the government can now issue protocols asking pharmacists to respond to a medicines shortage in one of four ways: to dispense a reduced quantity, a therapeutic equivalent, a generic equivalent or an alternative dosage form of the drug.

Under the protocol, the pharmacist would not have to consult the patient’s GP before making the switch.

The Good Law Project is now seeking to launch a judicial review of the amendments, partially on the grounds that the government’s initial consultation – which lasted one week on 5–12 December 2018 – was “insufficient and unlawful”.

In a legal document sent on 19 February 2019 from the group’s lawyers to the DHSC to inform them of their intent to start the review proceedings, the Good Law Project said it was “unclear exactly who the Secretary of State consulted with and how/on what basis”.

It added: “The failure to consult properly with organisations representing specific patient interests was unlawful.”

Ekklesia reports:

Jolyon Maugham QC, Director of the Good Law Project, said: “Both doctors and patients have proper concerns about their safety in the event of medicine shortages. We want the Government to withdraw the prospect of SSPs [Serious Shortage Protocols] until it has complied with its legal duties and consulted properly on their use. If the Government does not take this step, the Good Law Project will launch judicial review proceedings in the High Court.”

Professor Tamara Hervey, Specialist Adviser to Parliament’s Health and Social Care Committee, said: “In the event of a no-deal Brexit, there would be likely to be shortages of medicines. The absence of a legal framework for imports and exports drastically affects supply chains. Stockpiling plans cannot cope for more than a few weeks. This is a serious issue for people needing a regular supply of a particular type, strength and quality of medicine.”

Jane Hanna, Chief Executive of SUDEP Action, who is supporting the judicial review said “Patients, doctors and pharmacists are used to prescriptions and the processes surrounding them. For people with long-term conditions, like epilepsy, what is on the prescription may represent months and years of trying out the best medication schedule. Changes made to this delicate balance can for some, undo this in an instant. For epilepsy this could lead to less seizure control, impacting on quality of life (ie: losing a driving licence, affecting home and work) and significantly for some this can prove fatal.  At present if a supply of medication is made in error, lessons can be learnt because of the clarity of who signed and who supplied the prescription.

Deborah Gold, Chief Executive of NAT (National AIDS Trust) said: “We are deeply concerned that these changes were made without proper consultation. Prescribing HIV medication is a complex process which must take account of a multitude of factors. The only person qualified to safely alter the medication prescribed to a person living with HIV is that person’s HIV consultant.”

• The Pre Action Protocol Letter can be seen here

 

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Can I appeal to everyone, individuals and organisations, to get solidly behind the judicial review as loudly and forcefully as possible.

I’d like to see all of us highlighting and publicising the judicial review in our various communications and campaigns. We are trying in Wirral.

If the review succeeds entire awful council/CCG edifices of pooling and dissembling come tumbling.

If the review doesn’t raise the required £18k we’re all doomed no matter how vocal our local and national campaigns!

Come on! The price of a few glasses of wine/beer/flat white.

https://www.crowdjustice.com/case/justice4nhs-stage5-courtofappeal/

Cheers

Kevin Donovan

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Following the Judicial Review in London in July, NHS England quietly launched its promised public consultation on the Integrated Care Provider (ICP) Contracts on 4 August. The consultation closes on 26 October.  If the appeal granted at the other Judicial Review called for by 999 Call for the NHS in Leeds is successful, this ICP contract may yet be unlawful, but it is nonetheless essential that we respond to the feedback.

The ICP consultation document is a daunting read for most of the public. However, Health Campaigns Together (HCT) has provided expert answers to all 12 points in the public feedback document. 

HCT’s aim in providing these answers is to prevent flawed plans being adopted. They are seeking to prevent long-term contracts being signed that will undermine our NHS. This is in order to preserve any hopes of achieving a genuine integration of health and social care as public services, publicly provided free at point of use – and publicly accountable.

 

A reminder on what’s happened so far: There have been two judicial reviews on the Accountable Care Organisations and these Integrated Care Provider (ACO/ICP) contracts. And the courts found in favour of the NHS. But one of the campaign groups, 999 Call for the NHS, has now been granted permission to appeal. 

This is some very good news. But it also means NHS England is consulting on an ACO/ICP contract that may be unlawful. 

NHS England knew full well that an appeal was a possibility. Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the ACO/ICP contract. The consultation says that the Judicial Reviews had ruled in their favour. This consultation runs until 26 Oct.

 

We all know that this ICP consultation needs to be combatted and stopped. But in the meantime, here’s all the information you need to fill in the consultation feedback.

As stated, the judge in the London NHS Judicial Review said that the ACOs (now ICPs) should not be enacted until a lawfully conducted consultation was held, and any eventual ICP contract would have to be lawfully entered into.

Since then, NHS England have moved swiftly and stealthily into gear, and you will find their monstrous ICP ‘consultation’ document at this link.

And here is Health Campaigns Together on the subject at this link.

As you see, the consultation document includes 12 points for feedback and Health Campaigns together has provided suggested responses to these points – very good responses too, I think. You’ll find them at this link.

When you’re ready here is the direct link for public feedback to the document, just copy and paste from the Health Campaigns Together link above.

As stated, there is a move afoot to get the consultation suspended until after the appeal granted to the 999 for the NHS has been concluded, but it’s very important to counter what will definitely be lots of responses from the allies of NHS England. Otherwise they will be able to hail the result as a democratic mandate.

Health Campaigns Together say that it is OK to copy and paste HCT’s responses into the feedback boxes on the questionnaire, although if possible, it would be good if respondents could add a few tweaks of their own.

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 Court of Appeal grants NHS campaign group permission to appeal against NHS England’s new Integrated Care Provider contract

Some very good news – which also means NHS England is consulting on an ACO contract that may be unlawful.

They knew full well that was a possibility, despite their protestations in the consultation document that both Judicial Reviews had ruled in their favour.

(They have rebranded the ACO contract the Integrated Care Provider contract and their consultation runs until 26 Oct.)

We shall be putting out more info shortly about this.

 

The Court of Appeal has issued an order granting campaign group 999 Call for the NHS permission to appeal the ruling against their Judicial Review of the proposed payment mechanism in NHS England’s Accountable Care Organisation contract.

The Accountable Care Organisation Contract (now rebranded by NHS England as the Integrated Care Provider contract) proposes that healthcare providers are not paid per treatment, but by a ‘Whole Population Annual Payment’, which is a set amount for the provision of named services during a defined period. This, 999 Call for the NHS argues, unlawfully shifts the risk of there being an underestimate of patient numbers from the commissioner to the provider, and endangers service standards.

In April, the High Court ruled against the campaign group’s legal challenge to NHS England’s Accountable Care Organisation contract – but the group and their solicitors at Leigh Day and barristers at Landmark Chambers found the ruling so flawed that they immediately applied for permission to appeal.

Although fully aware of this, on Friday 3rd August – the day Parliament and the Courts went on holiday – NHS England started a public consultation on the Accountable Care Organisation contract – now renamed the Integrated Provider Organisation contract.

The consultation document asserts that the payment mechanism in the ACO/ICP contract is lawful, because:

“The High Court has now decided the two judicial reviews in NHS England’s favour.”

Steve Carne, speaking for 999 Call for the NHS, said

“It beggars belief that NHS England is consulting on a contract that may not even be lawful.

And a lot of public funds is being spent on developing the ACO model – including on the public consultation.

We are very pleased that 3 judges from the Court of Appeal will have time to consider the issues properly.

We shall shortly issue our stage 5 Crowd Justice appeal for £18k to cover the costs of the Appeal.

We are so grateful to all the campaigners and members of the public who have made it possible for us to challenge the lawfulness of NHS England’s attempt to shoehorn the NHS into an imitation of the USA’s Medicare/Medicaid system.

We will not see our NHS reduced to limited state-funded health care for people who can’t afford private health insurance.”

Jo Land, one of the original Darlo Mums when 999 Call for the NHS led the People’s March for the NHS from Jarrow to London, added,

“All along we have been warning about the shrinkage of the NHS into a service that betrays the core principle of #NHS4All – a health service that provides the full range of appropriate health care to everyone with a clinical need for it, free at the point of use.

Since we first started work two years ago on bringing this judicial review, there have been more and more examples of restrictions and denials of NHS care, and the consequent growth of a two tier system – private for those who can afford it, and an increasingly limited NHS for the rest of us.”

Jenny Shepherd said

“NHS England’s rebranded Accountable Care Organisation contract consultation is a specious attempt to meet the requirement to consult on a significant change to NHS and social care services.

We don’t support the marketisation of the NHS that created the purchaser/provider split and requires contracts for the purchase and provision of services.

Integration of NHS and social care services, in order to provide a more straightforward process for patients with multiple ailments, is not aided by a system that essentially continues NHS fragmentation.

This new proposed contract is a complex lead provider contract that creates confusion over the respective roles of commissioner and provider. It requires multiple subcontracts that are likely to need constant wasteful renegotiation and change over the duration of the lead provider contract. This is just another form of fragmentation, waste and dysfunctionality.

The way to integrate the NHS and social care is through legislation to abolish the purchaser/provider split and contracting; put social care on the same footing as the NHS as a fully publicly funded and provided service that is free at the point of use; and remove the market and non-NHS bodies from the NHS.

Such legislation already exists in the shape of the NHS Reinstatement Bill.”

The campaign team say they are determined in renewing the fight to stop and reverse Accountable Care. Whether rebranded as Integrated Care or not, they see evidence that it is the same attempt to shoehorn the NHS into a limited role in a two tier healthcare system that feeds the interests of profiteering private companies.

Steven Carne emphasised,

“It is vital that we defend the core NHS principle of providing the full range of appropriate treatments to everyone with a clinical need for them.”

999 Call for the NHS hope the 2 day appeal in London will happen before the end of the year. The Appeal will consider all seven grounds laid out in the campaign group’s application – with capped costs.

Details on the first instance judgment can be found here, and the judgment itself here.
David Lock QC and Leon Glenister represent 999 Call for the NHS, instructed by Rowan Smith and Anna Dews at Leigh Day.

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This article was first published at HIV i-Base on 25 April 2018.

The revised BHIVA Standards of Care for people living with HIV are primarily produced as a reference for commissioning HIV services. It also describes a minimum standard of care that HIV positive people can use as a reference.

These 90-page guidelines were last updated in 2013 and this third edition was launched at the 4th Joint BHIVA/BASHH Conference in Edinburgh.

The Standards was produced by a writing group of more than 90 individual doctors, health workers and people living with HIV. It was a collaboration with numerous professional associations, commissioners and community groups.

The main changes to this edition include:

  • Reducing the number of standards from 12 to 8, but with each one covering broader themes.
  • A new section is included on person-centred care. This includes wider aspects of social circumstances, including stigma and discrimination, self-management, peer support and general well-being. The importance of these issues are emphasised by this being an early chapter.
  • Recognising the new U=U consensus: an undetectable viral load means HIV cannot be sexually transmitted – with or without a condom (although some sections of the document have inconsistent information on U=U that will hopefully be quickly updated).
  • The section on complex care has been broadened with more detail about access to specialist non-HIV treatment.
  • Another new section covers HIV across the life course covers HIV treatment and care from adolescence to end of life. This includes palliative care in the context that ART might continue to work well to the very end of life.

There are now eight chapters covering major themes. Each chapter and subsection includes quality statements and auditable targets.

Standard 1 covers testing, diagnosis and prevention and the 90:90:90 goals to eradicate HIV. All three areas are ways to maintain and develop combination prevention. This includes increased testing, early treatment, viral suppression and PrEP. Combination prevention helped bring about the dramatic reduction in HIV transmission seen recently in the UK. HIV positive people are important partners in combination prevention.

Standard 2 is about person-centred care. This has been described as “the fourth 90” and focusses on the whole person, not just HIV. BHIVA say it considers, “desires, values, family situations, social circumstances, and lifestyles. And in so doing, the needs and preferences of HIV positive people can be responded to in humane and holistic ways.” It challenges HIV stigma and discrimination and works towards equality in health and social care. Social inclusion and well-being – crucially aided by peer support – are key to person-centred care.

Standard 3 covers HIV outpatient care and treatment. Anyone newly diagnosed must be seen by a specialist HIV doctor within two weeks and given access to psychological and peer support. In some cases this referral needs to be within 24 hours. There is no gold standard for measuring engagement in care, but transfer of care should be seamless whether a person moves home, is incarcerated or simply moves to another clinic. Increasing numbers of children living with HIV from birth are now becoming adolescents. Management by interdisciplinary teams must ensure successful transition to adult HIV services. A qualified doctor must prescribe ARVs and monitoring according to current national guidelines.

Standard 4 is about complex HIV care. Inpatient care must ensure that an HIV specialist is included in the hospital multidisciplinary team. HIV positive people are living longer and often go into hospital for non-HIV related problems. They may be cared for safely and appropriately in a local ward or clinic. But they must also be supported by immediate and continued HIV expertise and advice. HIV positive people must have access to specialist services for other conditions such as cancer. But clear protocols and agreed pathways are essential for safe delivery of services. This section also includes supporting people with higher levels of need. It includes successful management of multiple long-term conditions, poor mental health, poor sexual health, and problems with alcohol or substance use.

Standard 5 is on sexual and reproductive health. It is important that HIV positive people are supported in maintaining healthy sexual lives for themselves and their partners. In addition, anyone at risk of other STIs and infectious hepatitis, perhaps through drug use, should be supported and given advice. Care should be given for contraception, fertility services, pregnancy planning, and access to abortion services. Care must ensure that babies are born healthy and HIV negative. Care for the mother’s health is key to giving birth to a healthy baby.

Standard 6 is on psychological care. HIV positive people should receive care and support that assesses, manages and promotes their emotional, mental and cognitive wellbeing and health. This should be sensitive to the unique aspects of living with HIV. HIV positive people have higher rates of depression, anxiety, addictions, self harm, and other mental health issues than the general population. Mental health needs must be screened on an annual basis. This includes screening for poor cognitive function that can cause memory problems and reduce ability to perform simple tasks.

Standard 7 covers HIV across the life course. This section looks at standards of care for everyone who is HIV positive. Management of ART should be individualised at every age. It starts with adolescents (aged 10 to 19 years) and young adults (aged 20 to 24 years). Education and personal development – as well as achieving healthy sex lives and relationships – should be supported by experienced sexual health advisers and specialist nurses.

The years from 25 to 65 are described as early to middle adulthood. Most people in this age group are diagnosed as adults. Care for early diagnosis and treatment should include peer support as well as psychological support. HIV positive people should be supported in having healthy and fulfilling sex lives and engaged in treatment as prevention (U=U).

The over 65s – whether newly diagnosed or long-time positive – should be given access to treatment for complex comorbidities. This is an area of significant emerging knowledge and will likely develop over the course of these standards. Successful care may be achieved through co-speciality clinics, mentoring schemes, or by identified experts in advice and guidance. Palliative care is now included here. Palliative care ensures that the individual and their family are supported, receive appropriate care that meets their needs and preferences, and do not experience unnecessary suffering

Standard 8 covers developing and maintaining excellent care. This standard covers knowledge and training to ensure specialist services are provided. It sets standards for monitoring, auditing, research and commissioning. It also sets standards for public health surveillance, confidentiality and information governance.

Roy Trevelion was a community representative on the Standards writing group.

COMMENT

These comprehensive Standards are very welcome.

The community was involved at every stage from planning to the final draft, with at least one community representative on each chapter and more than 15 UK-CAB members collaborating overall.

The result is a comprehensive benchmark for health and wellbeing for HIV positive people.

All sections provide bullet points for measurable and auditable outcomes and must be promoted in primary and secondary care, health & social care, public health, and local authority healthcare provision.

As bureaucratic and structural changes affect the structure of HIV services, these Standards should be a reference for ensuring that high-quality care for HIV positive people is maintained.

The inconsistent messaging over undetectable viral load and HIV transmission will hopefully be corrected. As the publication is only available in PDF format, this should be relatively easy. Several formatting problems, including difficult legibility (light font, justified text) would benefit from being revised. 

It is good to see the inclusion of HIV positive people in the photographs throughout the report, supported by the UK-CAB and Positively UK.

Reference

BHIVA. British HIV Association Standards of care for people living with HIV 2018. April 2018.
http://www.bhiva.org/standards-of-care-2018.aspx

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In 2009 the internal market was abolished in the Welsh NHS. Seven unified Health Boards (and three trusts – Ambulance, Public Health and Velindre cancer services) took over the responsibility of the former 22 Local Health Boards and most of functions of the seven Trusts to both plan and deliver health care for the population resident in their geographical areas.

In the initial phase following the internal market abolition the acute hospital sector seemed to have “captured” the planning process. But as things have matured the Welsh Government has sought to re-balance matters with the introduction of Integrated Medium Term Plans (IMTP).

All NHS organisations are now expected to operate to three yearly IMTPs as part of their planning cycle. The latest framework covers the period 2018-2021 with yearly iterations providing firm plans for the initial year, indicative plans for Year 2 and outline plans for Year 3. At the heart of the process is the creation of a collaborative approach which will be sufficiently robust not only to withstand the continuing pressures of austerity but to deliver real improvement for patients, service users, carers and wider public health.

The planning framework ( http://gov.wales/docs/dhss/publications/171013nhswales-planning-frameworken.PDF ) and the IMTPs continue to be informed by the principles of “Prudential Healthcare” ( http://www.prudenthealthcare.org.uk/ ) and an emerging distinctive Welsh legislative backdrop including the Mental Health Measure (2010), Social Services and Well-being Act (2014), The Well-being of Future Generations Act (2015),  Nurse Staffing Levels Act (2016) and Public Health Act (2017).

The planning and delivery process needs to achieve the “Triple Aim” of improving outcomes, improving the user experience and achieving best value to money supplemented by the Parliamentary Review’s ( http://gov.wales/docs/dhss/publications/180116reviewen.pdf ) recommendation of enriching the well-being, capability and engagement of the health and social care workforce.

There are five priority delivery priorities outlined which represent a real effort to re-balance the Welsh NHS away from its initial over-focus on acute secondary care covering such areas as:-
Prevention
Tackling health inequalities
Primary & community care
Timely access to care
Mental health.

Each of these priorities are important in their own right. The prevention and tackling inequalities agendas acknowledge the social determinants of health but they also re-emphasise the importance of addressing “the inverse care law” which is about how the health service responds to the unequal health experience of people. Access to care is recognised as being both clinically important and a key quality measure of the patient’s experience. And as well as timely access to services the quality agenda requires that patients receive safe, effective, personal and efficient care in an equitable way.

Health boards and trust IMTPs must be the product of collective working that extends from the clinical experience of patients and NHS staff to engaging with a wider range of bodies outside the NHS family. Particular attention must be paid to the plans being developed by the primary care clusters ( http://www.primarycareone.wales.nhs.uk/primary-care-clusters ) as well input from traditional sources such as Public Health Wales. In addition participation in regional and local service boards, as well as bilateral discussions, must be used to co-ordinate planning and delivery with other public bodies such as local government, social care, education and housing.

The governance within the Health Boards and the wider NHS must improve if the planning process is to effectively identify and respond to local need. To date the record is not great. Health boards are not always adept at either identifying service failures or responding effectively to them. The Welsh Government has a clear pathway of escalating intervention when health organisations are struggling but even then improving performance has proven elusive ( http://gov.wales/topics/health/nhswales/escalation/?lang=en ).

The final report of the Parliamentary Review recommended that the Welsh Government itself needed to more pro-active in promoting innovation, evaluation and implementation of best practice across NHS Wales. The planning framework preceded the publication of the final report and its silence on the Welsh Government’s role in being a catalyst for service transformation is therefore missing. This needs to be rectified.

The abolition of the NHS internal market was widely welcomed in Wales. This in itself it does not provide automatic answers to all of the problems the NHS faces. But it allows for new ways of addressing them based on the principles of partnership, collaboration and public service values which are more clearly reflected in the latest planning framework guidance.

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We like to think that we own our NHS.  It’s a public service.  If we do own it, then the joke is on us.  The NHS is now an unaccountable secretive mess and our interests are not being protected.  The people tasked with looking after our interests are bullied or manipulated into amnesia.

We are supposed to have the most open and transparent health service in the world, pause here for prolonged laughter.  What we have is a howling mess with providers behaving like autonomous private companies and claiming commercial confidentiality over everything; meeting in private to keep things secret.

We have CCGs that commission £billions of services but have no accountability to the public they serve and who keep their business as private as they can.  They are even trying in some places, Staffordshire and Cambridge as examples, to evade all responsibility by transferring their responsibilities by contracting them out.  The next wheeze might now be Accountable Care Organisations (that could be private companies) and which have no accountability yet hold long term contracts to plan commission and deliver NHS services.  This is wrong.

We had the whole NHS being divided into 44 planning areas with Sustainability and Transformation Plans, making a brave attempt to overcome the chaos in the NHS caused by the dreadful Lansley Health and Social Care Act.  Most of these STPs came out without any semblance of consultation with the public, patients or staff or even with the local authorities they were supposed to have included.  Hardly a day goes by without some new idea for some new body yet none of them look like something we would be able to hold to account.

We have NHS bodies which are supposed to be public and which are paid through public funds behaving like the worst in the private sector.  There was the legendary Strategic Projects Team spending years advising on half baked schemes to privatise services, all of which failed.  The award winning SPT, set up initially to manage the Circle deal in Hinchingbrooke went from failure to failure but was never held to account.  A proper record of what they did and on what authority will never be made public, good luck with any FoI request.

QE Facilities

Now we have the new SPT – QE Facilities.  Again, an NHS body, again with insider status, going around the country charging Trusts for advising them about how to evade VAT by setting up a wholly owned company.  This publicly owned company has just refused an FoI request to list those Trusts it has spoken to.  This is commercially confidential – we are not allowed to know if one part of the public sector has spoken to another part.

The saga of forming wholly owned companies to avoid VAT has been the latest stain on the NHS.  Boards have gone down this route in secret, refusing to engage with the hundreds of staff involved – who will move out of the NHS.  They make public claims about improving services which are wholly untrue – their own figures show all the savings come from tax changes and service improvement does not feature.  They refuse to provide documents, meet in secret and refuse even to consult with their alleged partners in their local STP.

This behaviour by Foundation Trusts who do not even bother to involve their own Governors ( as they are not trusted) probably signals the end of the experiment with trying to get public bodies to behave like private companies.

These are the same Trusts that sign up to Sustainability (all the Transformation plan money has been nicked) Plans that are not sustainable and to control totals they know they have no chance of achieving.  We live in the fantasy world where Boards are too weak to say no, they just play the game.  Since almost every other Trust is in some kind of trouble retribution is unlikely.

Of course all this is in part a reaction to the absurdity that the legislative background is totally incoherent and is being largely ignored.  Yes, there are examples of people coming together and trying to do their best for patients by trying new ways of working.  All good.  But none of this gets us anywhere unless we make the funding available to make sustainable changes possible.  We get nowhere without decent workforce planning.  We fail if we don’t address the yawning gap in accountability.

We will fail unless we get better Boards that tell the trust not just to power but to their own staff!

As waiting lists grow and cancellations increase satisfaction with the NHS is beginning to fall; more people are opting to spot purchase private care, the clear signs of a system in deep trouble.

So if we are the owners how do we get our say?

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Instead of Accountable Care Organisations

The NHS in England is being reorganised, yet again. Jeremy Hunt and his advisors have decided to turn upside down their own previous reforms. Now commissioning organisations (CCGs) and service providers (NHS Trusts) will be brought together into large Accountable Care Organisations (ACOs). How this will work in practice is not clear and rightly there have been calls in Parliament to scrutinise the changes. A coalition of health campaigners, including Stephen Hawking, are also trying to take the Government to court to stop these plans.

In one minimal respect these changes are positive, for they could mark the end of the era of the internal market and commissioning. The Government’s austerity programme and the cuts, not just to the NHS, but in particular to social care, have further undermined the ‘purchaser-provider split’ and the complex tariff arrangements that are used to fund NHS service provision. Now, as demand rises, and real funding falls, it makes no sense to continue with this pseudo-market model, one that has dominated the NHS since 1992.

However the threat of continuing privatisation to the NHS continues. In fact the term ACO is an American term which is used to describe an insurance-based model for funding healthcare, one which is generally associated with low quality and highly rationed care. It is entirely feasible that the NHS is being parcelled up into large chunks which can then be taken-over by US companies for profit. Even if this does not happen immediately there is every sign that these new arrangements will worsen the quality of the NHS:

  • Even more privatisation, for larger contracts, won by larger profit-making corporations
  • Even more rationing according to bureaucratic tick-box systems
  • Even less connection to local communities and people
  • Even more centralisation of money and jobs in fewer places

Even if ACOs are not privatised they are certainly likely to adopt the kind of heartless rationing and contracting systems adopted by US companies to control costs. They will be so out of touch with real communities that anything more human or positive is not available to them.

Inevitably central government will try to reassure the public that they do not intend to do any of these things. They will likely talk about ‘working in partnership with local communities’, increased ‘personalisation’, ‘asset-based approaches’ and addressing the ‘social determinants’ of health. But, after seven years of austerity and regressive social policies none of these reassurances are remotely credible. Taking money, power and authority away from local communities and away from local government will only reduce local influence on the NHS. Austerity is a policy of central government and further centralising the NHS further will only make things worse.

Despite the lack of any clear democratic mandate, any clear policy and any legislation, there remains considerable momentum behind the drive from Whitehall to reorganise existing NHS organisations into ACOs.

So this short paper tries to offer some provisional answers to just two questions:

  1. What should we do in the short-run to resist these changes?
  2. What kind of new arrangements should we seek in the medium and long-term?

Urgent next steps

The first urgent priority must be for all those who care about the NHS and its future to make clear, at every opportunity, that they are opposed in principle to the development of ACOs, for the following reasons:

  • No case has been made for the use of the ACO model. There is no research to support taking a model developed in the worst-performing country for health care in the developed world (the USA) and using it to replace the system used in the best health care system in the developed world (the NHS).
  • In fact these changes are just a smoke-screen for cuts. The Government should be pressed to properly fund the NHS and social care, not to make radical organisational changes that will waste more money on new salaries, redundancies and consultancy fees. We should not be wasting our time on planning organisational change but overturning austerity.
  • There is no democratic mandate for the reforms. There is no legislation to support them and there has been no Parliamentary scrutiny of them.
  • ACOs are not statutory bodies and so, as the functions of local statutory bodies are moved into new regional entities, that work can be bundled together and privatised.
  • ACOs themselves are not democratic. They are not accountable to local people, neither directly by election, nor indirectly by the involvement of elected local councillors on their board.
  • ACOs do not respect local democracy and are disconnected from local identities. Their boundaries frequently make no sense to citizens nor to existing institutions. For example, the proposed South Yorkshire & Bassetlaw ACO effectively annexes part of Nottinghamshire into Yorkshire.

In particular, it is surely the duty of local government to reject this shift in policy and to refuse to cooperate with plans to establish ACOs (or similar non-statutory regional bodies).

Principles for change

Most of us who want to defend the NHS are united in wanting to see an end to the era of internal markets, privatisation and commissioning. However this does not answer the question of how we would like the NHS to be organised instead.

Even prior to 1992, when the era of commissioning began, the NHS has had a history of being constantly and pointlessly reorganised by Whitehall and London-based politicians. We all want a National Health Service – but not every decision can or should be made in London by a bureaucrat or politician. The NHS is one of the largest and most complex organisations in the world. Decisions need to be made at many different levels and in many different contexts, by citizens, professionals and democratic bodies.

To begin with we need to reflect more deeply on the principles that should underpin the long-term organisation of the NHS, and so I am going to propose 5 broad principles:

  1. Justice – The organisation of the NHS must be designed to promote social justice, not just by providing free high quality healthcare to everyone, but also by promoting income equality within its own salary structures and social justice in wider social structures (e.g. housing, social care, social security and education).
  2. Democracy – The NHS belongs to the people and it must be accountable to the people through established democratic structures and appropriate statutory bodies.
  3. Subsidiarity – The NHS is a large and complex system and decisions need to be made by the right people, at the right point. Some decisions should be left to citizens or to professionals; others must be made at the level of the local community or at appropriate regional levels. Only those decisions which really must be made nationally should be made in Whitehall (or Edinburgh, Cardiff or Belfast).
  4. Citizenship – The NHS must encourage a culture of trust, openness and citizen responsibility at every level of society. It is a public good, part of our common and shared inheritance and we all have a shared responsibility to develop and improve it for future generations.
  5. Stability – Constantly changing managerial structures undermines effectiveness, innovation and trust. The NHS needs to work within a framework which is much more stable over time. The costs of constant reorganisation far outweigh the putative and contradictory benefits of any proposed reform.

Democracy and the NHS

If these are the right principles then our goal over the long-run must be to push for significant positive reforms to apply these principles and to protect the NHS and strengthen its status as part of our common inheritance.

In outline the following steps for positive reform can be envisioned:

1. Constitutional reform – The right to free healthcare for all should be a constitutional right, protected not just by law but by further constitutional measures that would limit the ability of politicians to interfere unduly in the principles of the NHS or in the structures of local government. Such rights could be established alongside other economic and social rights – rights which the UK has signed up to internationally – but which it currently does not respect at home. Under the current administration the prospects of fundamental and positive change may well be very poor, but looking to the future it is quite possible to imagine changes in the constitution of the UK that would better safeguard the NHS and our social and economic rights more generally for the future.

2. Democratic control – Central government must guide overall policy and help define the general rules within which local people work. However there is no reason why people in different areas cannot make their own decisions about how they want to organise health care in their own communities. Developing a strong and sustainable welfare state means working through and with citizens and ensuring democratic accountability.

3. No ACOs – The idea of Accountable Care Organisation must be abandoned. It refers to US system which we do not want and which offers no value. It suggests additional accountability, but it in fact it is about reducing accountability. The idea is worse than useless and must be abandoned.

4. Stable local structures – Ideally the NHS would be organised around a stable configuration of local government boundaries and one that allowed for regional, local and neighbourhood levels of discretion, with suitable democratic structures at every level. However, currently local democracy in the UK is very weak and needs to be improved. Until better systems are developed the NHS must be organised around existing local authority boundaries. Any plan to make decisions at a level larger than the local authority – let’s call this an Area level – should only be possible with the explicit agreement of all local authorities within that area. It is totally unacceptable that NHS structures can be gerrymandered by Whitehall. Local authorities must agree to the creation of any area or regional structures that includes them.

5. Governance – If we accept the need for a larger decision making body beyond the boundaries of the local authority then let us call these Area Health Authorities. If there are no direct democratic elections to such Area Health Authorities then only existing local councillors from local authorities within that area have the necessary mandate to speak up for local people. Hence the board of the Area Health Authority must, as a minimum, be made up by a majority of locally elected councillors.

6. Management – Taking on the role of overseeing local health services is complex work and so a proportion of the significant existing resources currently spent on management within the NHS should be shifted into the direct control of local authorities.

7. Legality – Until any new statutory body, like an Area Health Authority, is created then the primary responsibility for delivering NHS responsibilities must lie with either an existing statutory NHS body or a local government body. There should be no risk that the management and over-sight functions are delegated to some non-statutory body which can be privatised or can avoid direct democratic scrutiny.

Although many of these potential reforms would certainly not be supported by the current Conservative Government it is not clear that other political parties would not support these principles. In fact several Conservative MPs are showing signs that the creation of ACOs is one crazy reform too far.

Nor is there any reason why local councils could not adopt some of these ideas a goals as part of their negotiations with the NHS, whatever the pressures from Whitehall. Currently Health & Wellbeing Boards are supposed to act as the guarantors of locally defined plans and appropriate shared accountability between the NHS and local government. In the short-run it should be these bodies who decide how local services are organised.

Shifting power away from local authorities and towards bureaucratically defined and unaccountable areas will do nothing to improve the NHS or to resolve its funding problems.

A short note on social care

There is a tendency to run together health and social care as if they are, or should be, one service. In fact the idea that health and social care can or should be integrated is a very dubious nostrum. There are good reasons why social care has remained stubbornly distinct from health care, not just in the UK, but around the world:

  1. Social care is predominantly focused on helping people live their lives as citizens, by respecting and supporting person autonomy – it is not a form of health care where the professional is largely the expert.
  2. Social care, because it is about the whole of life, must also be sensitive to issues of housing and education – not just health care – in fact for children education is a much more significant partner than the NHS.
  3. Social care is best organised in partnership with citizens, families and local communities, with support by systems of funding controlled by individuals.
  4. In practice social care can be organised by people and families, with support from national or local funding, and underpinned by local services. There are good reasons why local government will continue to play an important role in shaping social care and other local community services.

Clearly the current crisis in funding, which particularly targets social care and local government, is caused by the ideological commitment of the Government to drive down the level of public spending. This is putting the current system under tremendous strain. However this is not a reason to shift adult social care into the hands of the NHS. Instead local government must insist on their right to play its part in ensuring that local healthcare systems are designed to respect the rights and needs of local people.

Local government must not become a bystander, watching on as the NHS is pushed through another wave of chaotic organisational changes, instead it should be the champion of the interests of local people.

Conclusion

The idea that the NHS should be democratic and more accountable at a local level has been around along time. In fact it is, as I understand it, the policy position of the Socialist Health Association. However the debate about a more local NHS was derailed by the 1992 market reforms and since then the drift of policy has been to increased bureaucratisation and to central control.

Personally I think the Labour Party’s new stance, committing itself to the full renationalisation of the NHS, is entirely correct. I am hopeful that the era of mindless neoliberalism and meritocratic top-down management is finally tottering (if far too slowly) to a close.

So now is an excellent time to start thinking about the kind of NHS we really want.

We certainly want end to the crazy market systems; but surely we do not want to go back to an era of centralisation and to constant reorganisation. Perhaps it is time to consider entrusting the NHS to us – the people.

Further reading

These ideas reflect a long tradition of human rights developments around the world. These publications may be of interest:

Duffy S (2017) Heading Upstream: Barnsley’s Innovations for Social Justice. Sheffield: Centre for Welfare Reform.

Hunt P (2017) Social Rights Are Human Rights: but the UK system is rigged. Sheffield: Centre for Welfare Reform.

Potts H (2008) Participation and the Right to the Highest Attainable Standard of Health. Colchester: Human Rights Centre, University of Essex.

Potts H (2008) Accountability and the Right to the Highest Attainable Standard of Health. Colchester: Human Rights Centre, University of Essex.

First published by the Centre for Welfare Reform.

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The decision to accelerate the development of Accountable Care Organisations (ACOs) in England is unwise, unnecessary and should be challenged.  It is hoped the SHA will support the Judicial Review and the Early Day Motion from Labour.

Sadly ploughing ahead with the contracting model for ACOs without any proper explanation, consultation or engagement is typical of what the NHS has been doing, with the secrecy around Sustainability and Transformation Plans as a textbook example of how not to do things.  You cannot make changes on this scale without taking staff patients and public with you – and you should not try.

It’s time to stop, consult and think again.  In earlier communications NHS England were saying that it would be some years before the first ACOs could emerge – what is the hurry?

Moving to ACOs is a major change.  An ACO has its own legal form with a legally binding contract “for the majority of health {primary, communication and secondary including GPs} and care {social care} services and population health {mostly now with local authorities} for a defined area”. As NHS England has made clear the contract for an ACO will have to go through a proper procurement process.

An ACO need not be a public body but it will get income from public funds in £hundreds of millions and will plan and provide vital services for populations of hundreds of thousands.

ACOs are described in the limited documents so far as the next step along the path that started with the Sustainability and Transformation Plans, which are becoming Accountable Care Systems and only then ACOs.  In a few places like Northumberland some good progress has already been made but most Sustainability and Transformation Plans are still in cloud cookoo land.

The implications of moving to an ACO will be felt across both NHS commissioners and providers but also local authorities and many third sector and a few private sector organisations.  It has major implications and yet so far there has been little or no attempt to explain and consult about this with staff, patients and the public – it’s mostly the NHS talking to itself.  It will be yet another bail out of hospitals plan. Few local authorities accept they have been adequately engaged anywhere along this path yet they should be leading the process if it is about population health and wellbeing.

Concerns are obvious.  It is entirely possible, some would say inevitable, that an ACO will be led by or include a private sector organisation; as we have seen in earlier skirmishes around service integration in Cambridgeshire and Staffordshire, which failed spectacularly after early enthusiasm.

So how will these new bodies be held to account?  They are getting lots of public money so who decides how much and what outcomes are set for the contract?  How do local authorities and NHS control the money and the performance?  Are some staff still in NHS and others not?

The issues are many and complex and solutions have consequences.

In a public system, as in Wales and Scotland, the merits of ACOs might outweigh the disadvantages and we can already observe what is happening in our neighbouring countries as they progress in a more measured way to better integrate services; something known worldwide to be far from easy.  And even in market ridden England it is possible to use ACOs as part of a move to proper population based planning of services, to removing the commissioner provider split and to joining up better disparate services for the benefit of service users.

But a change on this scale will only have a reasonable chance of success if it builds on public understanding and support.  Nothing has been learned from the ludicrous antics of some Sustainability and Transformation Plans.

And to be clear the huge strain on the NHS and social care is due to inadequate funding with serious workforce issues as a consequence.  Forming a few ACOs will make little or no difference and could just be a distraction from making care as good as possible under almost impossible circumstances.

Stop now.  Explain.  Consult.  Think again.  What is the hurry?

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