Calderdale to set up USA Medicare/Medicaid-type NHS contracts and discourage “dependency” on health and social care

Calderdale Council’s Director of Public Health, Paul Butcher told the Health and Wellbeing Board meeting on 12th April 2018 that the Calderdale Council officer group are

“moving forward on implementation of the Calderdale Integrated Care System.”

They are working on two related tasks:

  • looking at ways of measuring the quality of population health outcomes
  • planning to set up a new type of large scale GP practice hub in North Halifax to serve a population of 30k-50K, called “primary care home”.

Bear with me, this is their jargon, not mine. I will try and translate it.

Paul Butcher said they are looking at metrics for population health outcomes, for example for cardio-vascular disease.

What is a population health outcome?

After the meeting, I asked Paul Butcher this question on twitter, which led to a rather fruitless conversation. So I resorted to an online search.

The NHS Innovation Accelerator webpage on outcomes based healthcare  indicates that outcomes typically measure both the presence of health and the avoidance of illness; and that population health outcomes can be measured for whole populations and for population segments – eg frail elderly, or groups of patients with cardiovascular diseases. And:

“The key focus is to … shift measurement and reimbursement away from solely treating illness, by establishing capitated budgets.”

Capitated budgets – aka whole population annual payments, or population budgets – are justified on the grounds that this payment mechanism incentivises providers to improve health and prevent illness.

In practice, evidence from Spain and the USA shows that they encourage cherry picking of patients who will be cheapest to treat and whose prognosis offers the best return on investment.

The garbled Calderdale Care paper to the 12th Feb Cabinet says that in 2018:

“A ‘neighbourhoods’ model will be established across the health and social care system as a basis for locality working. These areas should cover populations of roughly 50,000 and will manage whole population budgets.

Such budgets are key to the operation of Accountable Care Organisations that provide Medicare and Medicaid state-funded healthcare in the USA.

These whole population budgets are one of the founding principles  of the new type of “primary care home”  neighbourhoods model that Calderdale Council and Calderdale Clinical Commissioning Group are planning to set up in North Halifax, to serve between 30,000- 50,000 people. This principle is:

“Reducing costs and strengthening the deployment of care resources by an alignment between care decision-making and the financial consequences. This means that the care teams that do the work take responsibility for a whole population budget for that registered community.”

More detail is given in this article:

“The PCH [Primary Care Home] requires a whole population-based budget formulated on the registered lists of the constituent practices, with a level of funding dependent on the need of the population and the scope of responsibilities within the contract…”

Judicial Review of capitated budget arrangements in new Accountable Care Models contract

This payment mechanism is the subject of the 999 Call for the NHS Judicial Review of NHS England’s Accountable Care Models contract in Leeds High Court on Tuesday 24th April. Here’s the facebook event for the #Justice4NHS rally and Judicial Review

999 Call for the NHS think that it’s not only unlawful under current NHS legislation and regulations, but would lead to restrictions and denials of patient care.

This is because the payment mechanism’s drive to cut costs means that decisions about patients’ healthcare are based on financial considerations not clinical need. This is what is meant by “an alignment between care decision-making and the financial consequences” – one of Primary Care Home founding principles.

The providers would spend the money on patients whose treatment represents good value for money. This is NOT what the NHS is about. The core founding principle of the NHS is that it provides comprehensive healthcare for all with a clinical need for it.

New Primary care model in North Halifax as part of Calderdale Integrated Care System

Calderdale Council’s Director of Public Health, Paul Butcher, told the Calderdale Health and Wellbeing Board meeting on 12th March 2018 about

“developments around the primary care home model in localities.”

There is a scheduled meeting for North Halifax, between Calderdale Council and voluntary organisations, to see how the primary care home model would work there.

He didn’t explain what this model is and no one at the meeting asked – maybe they all knew – but the National Association of Primary Care says it means that:

“health and social care professionals with the voluntary sector come together as a complete care community to focus on local population needs and provide care closer to patients’ home.”

The National Association of Primary Care is promoting its partnership with estates partner GPI and Octopus Healthcare to “transform” primary care estate.

An article by the National Association of Primary Care President, James Kingsland, casts some light on the question of Paul Butcher’s mysterious work on metrics for population health outcomes:

“Current outcome metrics, particularly in relation to general practice performance, may need to be discontinued in preference for PCH population outcome metrics.”

Calderdale Clinical Commissioning Group Chief Officer says current NHS and social care is a “dependency model”

The Calderdale Clinical Commissioning Group Chief Officer, Matt Walsh, announced that the Calderdale Integrated Care System was

“a genuine attempt from the lead agencies in Calderdale to do something better for the population.”

He then rather undermined this claim by adding ,

“We are determined to establish a different sort of relationship with the people we serve. We will test new ways of working that move away from the dependency model of care.”

Describing current NHS and social care services as an undesirable “dependency model of care” doesn’t exactly sound like doing something better for the population. It sounds more like Charles Murray’s neoliberal claims that welfare encourages dependency and creates an underclass, which have been used to justify cutting benefits and restricting people’s access to them.

In 2014 Cllr Tim Swift disagreed  with the following statement about dependency in the Calderdale NHS organisations’ strategic outline case for ‘integrated’ health and social care:

“the traditional model of care and support is no longer sustainable and…encourages dependence…evidence indicates that people in Calderdale spiral into a cycle of dependency and escalating support needs.”

Cllr Tim Swift said then,

“This is not a fair description of how social care now operates in Calderdale… there is good evidence of the progress we are making. For example, Calderdale has the second best performance in the region in keeping people out of care homes until it is absolutely necessary. We have put a strong emphasis on investment in reablement services. Even in the current financial crisis, we have been able to keep eligibility criteria at moderate – if we were working in the way described in this document then we would no doubt have had to join the 88% of local authorities who have raised their criteria to substantial or critical.”

Matt Walsh went on to tell the Health and Wellbeing Board that North Halifax has “self-identified” as a site for the primary care home model, and the Calderdale Integrated Care System

“would test out models on the ground, learning by doing from the bottom up.”

But aren’t NHS and social care staff meant to know what they’re doing, rather than use patients as guinea pigs? And how can you train Uncle Tom Cobbley and all, who are apparently to be an essential part of the redesigned primary care home workforce, if you can’t tell them what they’re supposed to be doing, when, where and how?

NHS England says

“Primary care home shares some of the features of the multispecialty community provider (MCP) – its focus is on a smaller population enabling primary care transformation to happen at a fast pace, either on its own or as a foundation for larger models…

Four key characteristics make up the primary care home:

•an integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care;

•a combined focus on personalisation of care with improvements in population health outcomes;

•aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards;

•provision of care to a defined, registered population of between 30,000 and 50,000.”

The personalisation of care bit seems to imply increased use of personal health and social care budgets. The government is currently consulting on a significant expansion of the scope of public health budgets in England.

Plans to ‘create a local market’ in health and social care, including personal budgets, threaten to undermine our collective rights and our systems based on social solidarity.

The 2014 Calderdale Strategic Outline Case for NHS and social care reconfiguration (which became the Right Care Right Time Right Place plan – now referred to the Secretary of State) proposed taking the power to assess social care needs away from Calderdale Council and said that in future the Council would merely give ‘information and advice’ to people who ‘will often make use of their own resources to self-fund care and support’.

In 2014 I reported  that the plan was for the Council to ‘create a responsive local market’ for social care and somehow ‘inspire and oversee care providers’ by a system of payments based on outcomes such as keeping patients out of hospital.

It now seems that this system of payments based on outcomes is the whole population annual payment or capitated budget. Which we are taking NHS England to court about.

This is not the way to modernise the NHS and social care and we will go on fighting to protect #NHS4All and bring #Justice4NHS

In response to a question about this, Cllr Tim Swift has written:

There are no plans to change the nature of any contracts in this way during the “shadow year”. We recognise the shortcomings of the tariff system with its perverse incentives. However, any change to a capitated system would be a major change and would be considered – in public – at the Health and Wellbeing Board as well as Cabinet and the CCG Board before it was introduced.
The CCG has agreed an Aligned Incentive Contract with CHFT for 2018/9 and so has changed the basis upon which the contract for acute services will work, but it remains an NHS contract in line with the regulations. It is not a capitated whole population budget.

All the questions and answers to the April Health and Wellbeing Board are downloadable here (pdf).


  1. That is what the conservatives have been pushing for years anything than to put income tax up so the rich don’t pay a larger portion and most of the wealthy have private insurance . Just another way of taxing the poor .And did you all know the conservatives have already sold off large lumps of the NHS to Branson and Medicare.


    • Not to Medicare I don’t think. This is the USA’s publicly-funded health insurance programme for people who can’t afford private health insurance. But USA companies like Optum and Centene (via a UK subsidiary) are certainly getting NHS contracts and looking for more.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.