ACO

  • By Dr Graham Winyard - published by Politics.co.uk on 15th January 2018.  Dr Graham Winyard is a former medical director of the NHS and deputy chief medical officer.

    Brexit's dominance of media coverage and parliamentary time is providing the perfect cover for controversial reform of the NHS by stealth. 

    Jeremy Hunt and NHS England's latest big idea is Accountable Care Organisations (ACOs). These bodies would be allowed to make most decisions about how to allocate resources and design care for people in certain areas.

    At the moment, that's done by public bodies whose governance is regulated by statute, set up by parliament after wide consultation and sometimes fierce debate. ACOs, by contrast, can be private and for-profit bodies. They are not mentioned in any current legislation and would have no statutory functions. They are not subject to the statutory duties imposed on other parts of the NHS.

    Although NHS England plan to get several ACOs up and running this year, no detailed policy proposals have been presented to parliament or the public. Indeed, details are so sparse that the House of Commons library briefing is forced to use definitions provided by the King's Fund, a health think tank.

    Hunt is planning to lay a raft of secondary legislation - which doesn't require a full parliamentary vote - in February, so that the first ones can be up and running by April 1st.

    The ACOs are going to be given long-term commercial contracts of between ten and 15 years. We know these are difficult to get right and expensive to get out of. Think of Virgin and the East Coast Main Line or the private finance initiative, which has left the NHS paying hundreds of millions to offshore finance companies for hospitals that cannot now be afforded. Warnings about risks of PFI were once brushed aside as alarmist, often by the same people who now dismiss criticism of ACOs in similar terms.

    I'm working with four colleagues to challenge these proposals through judicial review. Our case is not concerned with whether ACOs are a good or bad idea. That's for parliament and the public to decide, not the courts. Our case is that such a radical and significant change cannot lawfully be introduced and implemented without public consultation, parliamentary scrutiny and primary legislation. The case was filed on December 11th and clearly struck a chord with the public. They've provided £176,000 through crowd funding in over 6,000 donations.

    We are also deeply concerned that by using contracts instead of statute to allow ACOs to operate, the government is exposing the NHS to major risks.

  • by Allyson Pollock, who is professor of public health and director of the Institute of Health and Society at Newcastle University, and the author of "NHS PLC"; Published on 18th January 2018 in the "New Statesman"

    See Prof Pollock's TED talk "Privatisation of the NHS" - 29th April 2014 - in "Videos"

    Proposals for the health service will put billions of pounds of contracts into the hands of similarly structured organisations.

    It increasingly looks like the collapse of Carillion will not only cost the UK many millions of pounds but also endanger the delivery of vital public services and projects. And yet, even as the government scrambles to clean up the mess left by the contractor’s failure, it is currently proposing to allow NHS services to be put into the hands of companies which operate in the same way.

    Carillion already has a raft of NHS Private Finance Initiative (PFI) and Local Improvement Finance Trust (LIFT) contracts in the NHS, including owning and operating 11,000 hospital beds in a dozen NHS hospitals in England and Scotland as well as several General Practitioner (GP) surgeries and community services.

    Under the PFI, builders, bankers and service operators like Carillion, rather than government, raised money and entered into long term 30-year contracts with public bodies to pay back the debt. The extortionate costs to the taxpayer of this private borrowing are well documented. In the case of the NHS, which has been paying consortium members including bankers and shareholders a high annual charge for private finance, this is fueling serious financial difficulties in many hospitals and across the NHS. With money diverted to private pockets, beds and services have closed and staff have been reduced.

    [for more on "Accountable Care Organisations" - the "next big thing" for the NHS]

  • The Nuffield Trust has published its own research into the credibility of the proposals to shift care into the community, the proposals which underlie Simon Stevens' "Five Year Forward View" (2014) and its implementation in the 44 regional "Sustainability and Transformation Plans" (STPs) (2016).

    The Nuffield Trust  "Shifting the balance of care: Great Expectations" was published in March 2017.

    I have selected two key messages from the report:

    ....• Nonetheless, in the context of long-term trends of rising demand, our analysis suggests that the falls in hospital activity projected in many STPs will be extremely difficult to realise. A significant shift in care will require additional supporting facilities in the community, appropriate workforce and strong analytical capacity. These are frequently lacking and rely heavily on additional investment, which is not available.

    .....• While out-of-hospital care may be better for patients, it is not likely to be cheaper for the NHS in the short to medium term – and certainly not within the tight timescales under which the STPs are expected to deliver change. The wider problem remains: more patient-centred, efficient and appropriate models of care require more investment than is likely to be possible given the current funding envelope.

  • STPs and Five Year Forward View – the case of the missing evidence

    This is a very important and thorough, but brief (16 pages) summary of the problems as at April 2017 by John Lister, head of Health Emergency and Health Campaigns Together, who has monitored the NHS for 30 years.

    By way of praise I will borrow the following introduction by Eric Leach, of Ealing Save Our NHS, who edits "Our NHS in Crisis", as follows:

    "I have read some excellent pieces of research and writing in the five years I have been trying to make sense of the cost cutting/service change plans for local, regional and national care services.

    However one document now stands out in my mind as the most brilliant piece by piece, issue by issue, aspiration by aspiration shredding of the Government’s current plans and supporting evidence for delivering future financial savings and care services’ improvements.

    The document is attached. It’s written by John Lister and can also be viewed at www.healthcampaignstogether.com

    I realise it’s a long read at 16 pages, but I doubt anyone could cover the territory in fewer words/pages. His evidence base is authoritative, comprehensive and wide ranging. No sane person could conclude that there is any credible evidence that implementing the current plans will achieve either of the twin goals of extreme cost cutting and service improvement.

    If journalism is "early history" then John has documented in his paper why the STP/FYFV/ACO/Next Steps failed way before 2021".

  • By Neil Roberts  From GPonline.com - 27th April 2017

    "The government is 'relaxed' about the crisis in general practice because it thinks Labour can't win the general election, a former GP and health commentator has said.

    Former GP Dr Phil Hammond, who covers health policy for Private Eye, said that ministers were ‘very relaxed’ about the NHS because they believe there is no effective opposition.

    Plans to create large-scale Accountable Care Organisations to run health and social care services across the NHS would eventually lead to all GPs becoming salaried employees, he added.

    Citing a source ‘close to Jeremy Hunt’ Dr Hammond told the annual conference of Londonwide LMCs (Local Medical Committee) on Thursday: ‘They don't believe that Labour is electable. They are very relaxed about the state of the NHS, very relaxed about the queues in casualty, waiting lists going up again, and the disaster in general practice, because they don't believe Labour offers a credible opposition.’

    Dr Hammond said the Conservative government viewed the NHS as ‘a service for poorer people’ and wanted those who can afford it to take out private medical insurance.

    NHS privatisation

    ‘They want private companies to do as much NHS work as possible. And they want the NHS to be allowed to do as much private work as it wants to do. That is their ideology and agenda and they don't believe there is an opposition fighting that.’

    Dr Hammond, who was one of the first journalists to expose the Bristol babies heart scandal in the 1990s, warned GPs that under NHS England drive towards accountable care systems they could all end up in a salaried service.

    The NHS, he said, was ‘keen to move to a model of accountable care organisations where we unify primary, secondary care, social care.’ 

    He added: ‘Ultimately this will make all GPs salaried and working for a large accountable care organisation in a particular area.’

    The Conservative Party did not respond to a request for comment".

     

    SOH  Comment:

    The vast majority of the electorate know nothing about this. It has not been alerted to the detail of Health and Social Care Act 2012 and Simon Stevens' plans from 2014 for co-called "Sustainability and Transformation Plans". The STPs include American-style "Accountable Care Organisations" - the stress is on the word "accountable" or "cost-controlling". They are part of an entirely new and untried, root-and-branch reorganisation of the NHS which the present Government is bringing in very, very quietly.

    The NHS will be unrecognisable. The National Health Service will disappear and be replaced by many Regional ("footprint"-based) organisations linking local federations of GPs, local acute services and local government authorities. Each "footprint" organisation (ACO) will have a capped budget - no more deficits, no more overspending. Gone over your budget? No more medical service.  The management of the local ACO will devote its energies to finding ways to "deny service". Uninsured and poor Americans know all about this.....

  • Calderdale and Kirklees 999 Call for the NHS - article of 10th November 2016, updated on 9th March 2017 for the Budget announcements.

     

    Far from the Sustainability and Transformation Plans marking the government’s shift away from NHS marketisation and privatisation – as some are mistakenly claiming – the opposite is true!

    Since the Autumn 2015 Comprehensive Spending Review that created the Sustainability and Transformation Fund, both the government and its quango NHS England have explicitly linkedthe Sustainability and Transformation Plans to the requirement to “encourage” increased private sector involvement in the NHS.

    Update 9 March 2017

    Behind the derisory £325m STP funding in Hammond’s Spring Budget (for a few “most advanced” STPs)  is the plan for 50% of STP funding to be sourced from private companies via Local Economic Partnerships by 2020 – please see section below: “Strategic partnerships with the NHS and the 39 Local Economic Partnerships”

    Some key aspects of STPs’ mandatory “encouragement” of long term NHS “partnerships” with the private sector include

    • Strategic partnerships with the NHS and the 39 Local Economic Partnerships.
    • The abandonment of  “old-style contracting” and the  imposition of private company-friendly contracting.
    • Embedding digital technology in STPs.
    • They came from all over the country united in their concern for the present state of the NHS and their fears for its future. Different sources estimate attendance from "tens of thousands" to 250,000.

      Three women dress in white medical suits and hold placards reading 'Slash Trash Privatise', 'Don't be a Silent Witness' and 'Death Closer to Home' near Russel Square today. The protesters are set to be rallied by Bernie Sanders's brother

      From "Save Our Services Cumbria" (Whitehaven Hospital), to "Hands off Huddersfield Royal Infirmary", to "Calderdale 999Call for the NHS" (above), to "Defend our NHS York", to "Bristol Protect our NHS", to "Sussex Defend the NHS", all were protesting about planned or actual A&E, acute units or whole hospitals closures. Health Campaigns Together  and the People's Assembly had done a superb job calling together dozens of NHS campaign groups and organizing the biggest NHS demonstration in central London in decades.

    • Please come to a public meeting at 7pm at Hammersmith Town Hall on Tuesday 29th November to hear and discuss the response of H&F Council to the latest proposals for cuts in health services in NW London called the "Sustainability and Transformation Plan" or STP.

      The plan involves a complete upheaval of every service, from community care to mental health services to GPs to A&E departments to acute beds in the major hospitals, in NW London. The central aim of the plan is, we are told, to save money: a staggering £1.3 billion over the period to April 2021.

      Hammersmith and Fulham Council strongly opposes the STP and has voiced its opposition to the NHS bodies concerned.

    • New NHS plans - forward view, frightening, or fudge?

       

       

      The new NHS plans published yesterday ask for £8bn - more than any of the big three parties are offering - and offer £22bn of savings. But we've heard such promises before - where will they come from?

       

      Will new NHS plans get us out of the woods? Image: Nicholas Tonelli / Flickr. Some rights reserved.

       

      Simon Stevens’ Five Year Forward View document is being reported in much of the press as a call for an £8 billion increase in NHS funding by 2020, to facilitate a raft of other policies aimed at reducing demand on hospitals and improving efficiency.

      Even those suspicious of Stevens’ history in the US private medical corporation UnitedHealth, and as a Blair aide in opening the NHS up to the private sector, should be pleased to see him raise the need for more funding – asking for considerably more than any of the main parties have yet proposed.

      But his cagey interview on BBC Radio’s Today programme yesterday, in which he dodged questions on the role of the private sector and PFI, didn't help allay suspicions of some of his proposals. While his plans to reorganise local services are a long way short of a full-blown blueprint for privatisation, it certainly offers the potential for private corporations seeking to leach profits from the NHS budget.

      The report itself is evasively worded. It appears to focus mainly on NHS provision.

      It defends - if a little tentatively - core NHS principles, saying “nothing in the analysis above suggests continuing with a comprehensive tax-funded NHS is intrinsically undoable”.

      The briefings around Stevens’ proposals are significantly different from the Report itself. The £8 billion figure does not appear in the 39-page document, and nor does the accompanying figure of £22bn further “efficiency savings” (or demand reduction) that the Report says will be needed to bridge a £30 billion projected financial gap in NHS funding.

      £30 billion is the widely agreed ‘gap’ between resources and demands for the NHS over the five years from 2015, if coalition spending plans to freeze funding in real terms prevail. The three main parties are living in denial.

      Stevens’ report correctly points out that ‘flat funding’ along these lines ignores population growth, and could result in a reduction in real funding per head.

      Stevens points to the astonishing success of the NHS in largely maintaining services despite the spending freeze since 2010, and acknowledges the sheer effort and dedication of staff that has made this possible.

      But he glosses over the fact that a third of the apparent “savings” since 2010 have been at the expense of massive reduction in real terms salaries of the million NHS staff whose pay has been frozen since 2009.

      It’s clear to all but Jeremy Hunt that another five years of the same cannot be delivered.

      Stevens gives a brief nod to pay, suggesting “as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff”.

      If this means more pay, it will require considerable new investment.

      As will promises to:

      ·        Radically upgrade prevention and public health

      ·        Give “new support” to 1.4 million full time unpaid carers whose efforts keep the NHS afloat.

      ·        Give “resources and support” to the introduction of “radical new care delivery options” throughout England – among them new “multispecialty community providers” bringing together GPs, nurses, community health services and mental health, employ hospital consultants, run community hospitals and have admitting rights to hospital beds.

      ·        Give more NHS support for frail older people living in nursing homes.

      ·        “Invest in new options for our workforce, and raise our game on health technology”.

       But where will the money come from? Many of these are good ideas, but the price tag is never discussed.

      Stevens claims that some of the investment will eventually deliver record levels of efficiency savings. But he doesn’t explain how.

      Take the plan for “multispecialty community providers”. This is an even more ambitious revival of Lord Darzi’s controversial plans for “polyclinics” that were resoundingly rejected by most GPs and by local communities seven years ago. Despite government pressure only a few, expensive and unsuccessful, Darzi clinics were built – and most of them have since closed.

      Now, as then, Stevens offers no serious discussion of the costs of the new modern buildings, equipment and professional staff that would be required to deliver this.

      The plan potentially hugely fragments services currently provided in hospitals, with GPs employing hospital consultants in much smaller localised units serving very much smaller populations. This might sound good - but Stevens doesn’t it explain how it will do anything to reduce costs.

      He does at one point suggest a “pump-priming” by “unlock[ing] assets held by NHS Property Services, surplus NHS property…”

      Stevens also offers us a diametrically opposed alternative to GPs employing hospital doctors - that in some areas, Foundation Trusts in some areas could begin to run primary care, becoming “primary and acute systems”.

      Stevens worryingly compares these with “Accountable Care Organisations” now developing in the US and “other countries”, often under private ownership.

      He also offers “Clinical Commissioning Groups” the option of “more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services.” Stevens ignores the reality that far from being “led by GPs” as he suggests, most CCGs are largely run by managers or by Commissioning Support Units and management consultants.

      And he sets out hopes that prevention and health promotion changing people’s behaviour and lifestyle to reduce the demand for hospital care.

      We’ve heard most of this before.

      A shift from hospitals to ‘the community’, ‘alternative settings’ or ‘closer to home’ has been set out in every plan for hospital ‘rationalisation’ in the last 20 years or more - underpinned by the assumption that more localised services would somehow be cheaper. But there’s no evidence they are. As a result, even as local acute hospitals are undermined in the teeth of local opposition, community health services remain desperately under-resourced and further fragmented by repeated outsourcing and contracting.

      And few GPs - except the most entrepreneurial - want to deal with the administration required to deliver such models.

      More health promotion and prevention of ill-health is obviously a good thing. But it’s hard to change ingrained behaviour. Many of the health promotion targets have been wildly unrealistic, and the resources allocated to them completely inadequate. Time and again the burden of ill health among older adults that has already resulted from previous decades of less than healthy diet and behaviour has been underestimated.

      There is no quick fix. Hospital attendances and admissions have risen throughout this same period - compounded by the massive cutbacks in social care, which are set to continue under Osborne’s public spending plans.

      The result: intensifying pressure on the remaining hospital services - now taking the form of huge, under-funded demand on A&E, lengthening waiting times, and more delays in discharging patients from hospital for lack of suitable support in the community. A recent report in the Times shows the decline since 2010:

      ·        The number of people waiting for operations has gone up by one million to 3.3million people.

      ·        People are now waiting on average 10% longer for treatment.

      ·        The numbers waiting over 18 weeks and over 26 weeks for outpatient appointments and treatment have gone up by 25%.

      ·        Cancer treatment targets have been missed for two successive quarters.

      ·        For well over a year A&E departments have been failing to hit targets for treatment within 4 hours.

      ·        Trolley waits for a bed have almost trebled in the last three years.

      ·        Last minute cancellation of operations last year hit the highest level for nine years.

      ·        Delayed discharge of patients fit enough to leave hospital have hit a new record level.

      ·        60% of patients have to wait more than 48 hours to see a GP.

      Both hospitals and GPs are clearly under huge pressure. Before doing anything that could undermine them, new services have to be put in place to ensure patient care is improved. This needs money and will take time.

      Some of Simon Stevens’ ideas may help - if there was money to pay for them. But - whilst the three main parties have professed their welcome for Stevens’ plan, none have pledged to increase spending by anywhere near the £8 billion above inflation he says is needed by 2020.

      And it’s unclear how his plans would generate anywhere near the hugely ambitious £22 billion savings target he sets.

      Given this, his plan lacks credibility.

      It’s noticeable that none of Stevens’ proposals to boost efficiency takes on the costly and wasteful elephant in every CCG and Trust boardroom – the inflated transaction and overhead costs of running the NHS as a competitive market.

      Instead, his plan leaves room for private sector inroads that would further destabilise struggling and indebted NHS Trusts and contribute nothing of value to patient care.

      Campaigners will have to fight on for genuinely alternative plans for the NHS. We need a short term increase in funding - followed up by efficiency savings based on stripping away the wasteful bureaucracy of the market. And we need longer term plans to get the rich and big business to pay their fair share of tax towards public services we all need, but which are being starved of resources.