Smoke, Mirrors and Waffle: Cornwall Accountable Care System Inquiry Report

While Cornwall Adults Health and Social Care Scrutiny Committee is faffing around with a smoke, mirrors and waffle report from their Accountable Care System Inquiry group – prepared for their meeting on Monday 5th Feb – Kernow Clinical Commissioning Group has come out with much sharper information in its paper on the same topic – ‘Integrated Strategic Commissioning’ – for its 6 Feb Governing Body meeting.

This casts doubt on the accuracy and transparency of the Accountable Care System Inquiry Report, and raises the question of why the group that the Council Scrutiny Committee has delegated its investigation to, would want to obscure the facts that the Clinical Commissioning Group paper clearly spells out.

Here are 20 Questions for Cornwall Scrutiny 5.2.18 for Cornwall Adults Health and Social Care Scrutiny Committee on 5 Feb.

Evidence or waffle?

The Accountable Care System Inquiry report is full of waffle about “evidence” – which turns out to mean what the “stakeholders” told the Inquiry. This could amount to anything – facts, opinions, whatever, since there is no summary or appendices to show the content of stakeholders’ submissions to the Inquiry.

So who knows what this “evidence” amounted to? Did it have any factual basis, did the Accountable Care System Inquiry group check any facts that were presented to it? Did  it amount to anything more than opinion and views?

The Accountable Care System Inquiry’s negligent vagueness isn’t helped by its admission (Appendix 2, para 4.7) that,

“There had been no clarification of the differential between strategic and tactical commissioning.”

So they are making recommendations about Integrating strategic commissioning without saying what that is. Did they tell the members of the public and NHS and social care staff who took part in the Inquiry? Or did they keep them in the dark too?

However Integrating strategic commissioning is described  in Table 2 in the Kernow Clinical Commissioning Group paper. A key point that needs clarifying is its statement that

“[T]he system would need to ensure achievement of financial balance and future sustainability and the strategic commissioning function would be required to assure this is in place.”

How would this work? Presumably this is one reason why the recommended “new
commissioning vehicle” would require “use of legal framework to pool resources to a far greater extent”.

Why does the Accountable Care System Inquiry Report gloss over the whole issue of what Integrated Strategic Commissioning is? And what kind of legal framework for pooling resources would be called for?

And the Accountable Care System Inquiry’s failure to tell us what the “evidence” was makes their Report entirely hollow and vacuous.

This doesn’t prevent it from claiming that “the balance of evidence received” determined its recommendation of Option 6: that strategic commissioning to be undertaken through “a new vehicle.”

Little evidence or policy to guide the move towards Accountable Care Systems

In contrast, the Kernow Clinical Commissioning Group paper for the 6 Feb Governing Body admits right at the start that:

“The national move towards Accountable Care Systems has little evidence or policy to guide it at this point.”

As well as the discrepancy between their claims about the existence of evidence for the move towards Accountable Care Systems, the Accountable Care Systems Inquiry Report and the Kernow Clinical Commissioning Group paper also seem to differ over significance of the formation of a Cornwall Accountable Care Partnership.

Has the Scrutiny Committee abandoned its duties and responsibilities?

The Accountable Care Systems Inquiry Report states as an aside in 4.9 “However the Panel recognised that there was the development of an accountable care partnership…” and proposes that

“further scrutiny may allay public concerns.”

The function, duty and responsibility of Scrutiny is NOT to allay public concerns. It is to carry out thorough, impartial, evidence-based investigations of significant changes to Cornwall’s NHS and social care, in order to make sure that they are fit for purpose and will not damage the health interests of the public – or indeed the NHS and social care services themselves.

So what about Scrutiny Committee concerns? Are there none? Has the Scrutiny Committee abandoned its duty to scrutinise – and instead assumed the task of propagandising?

The Sustainability and Transformation Partnership has agreed to develop an Accountable Care System and Accountable Care Partnership by 2019

This is all the more worrying in the light of the Kernow Clinical Commissioning Group paper for the 6 Feb Governing Body, which unequivocally states:

“Through the development of Shaping Our Future, the health and social care organisations in Cornwall and the Isles of Scilly (CIOS) have agreed to develop one Accountable Care System for the county by 2019, comprising an integrated strategic commissioner for health and social care and a network of providers with a single leadership team, forming an Accountable Care Partnership.”

para 1.8 adds

“[T]he intention is for the system to be working as a shadow ACS by April 2018.It is proposed that the ACS will comprise an integrated strategic commissioner for health, care and wellbeing services, with a network of providers overseen by a single leadership team within an Accountable Care Partnership.”

Accountable Care System Inquiry Report’s coyness about what option 6 means

The Accountable Care Systems Inquiry Report is coy about not wanting to mention a “delivery vehicle” for integrated strategic commissioning. In contrast, the Kernow Clinical Commissioning Group Governing Body paper (para 2.2) says:

“Achieving the aims of an integrated strategic commissioning function is likely to
require new organisational constructs and revised governance arrangements.”

Why is the Accountable Care Systems Inquiry not reporting any of this to the Scrutiny Committee tomorrow? It would seem to entirely belie their Report’s claim that a business case for integrated strategic commissioning – which is what they’re recommending as a next step – doesn’t imply that any decision has been made about progressing to an Accountable Care System or Accountable Care Partnership or whatever.

It is to be hoped that the Scrutiny Committee will ask this and many other questions for itself.

Capitated outcomes-based contract is currently subject to a Judicial Review

The Kernow Clinical Commissioning Group paper says that the Secretary for Health and Social Care has recently announced that the progress of Accountable Care Organisations and their proposed contract vehicles will be paused to enable further consultation and consideration. It asserts,

This does not impact on the development of Accountable Care Systems and Partnerships.

However, this surely depends on whether Accountable Care Systems and Accountable Care Partnerships’ contracts use the same payment mechanism as the draft Accountable Care Organisation contract that is being challenged in a Judicial Review to be heard on 24th April. The grounds for this Judicial Review are that the per person payment for an area’s population is unlawful.

Table 2 in the Kernow Clinical Commissioning Group Governing Body paper states

“As the ACS matures, it would be responsible for developing and managing the outcomes and contractual framework for a capitated outcomes-based contract.”

Which seems pretty clearly to involve the same payment mechanism as that in the Accountable Care Organisation contract which is the subject of the 999 Call for the NHS Judicial Review .

Also, is the Scrutiny Committee aware that in November 2017, the NHS Improvement Board gave

“Consideration…to the legislative framework which was not currently set up to
support the ACS model”?

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