Accountable Care is stealing our #NHS4All from us. We’re going to get it back.

At the #NHS4All action planning meeting in Leeds on 16 June, the focus was on resisting and rolling back the imposition of USA-style Accountable Care on our NHS.

The meeting started with this info dump on the Accountable Care Models that are being flown into the NHS: What are Primary Care Networks, Integrated Care Systems and Integrated Care Providers? How will they affect patients and staff? Why are we resisting them? How is all this playing out in specific areas?

Integrated Care Systems are basically Sustainability and Transformation Plans with knobs on

The same aims prevail. They include cutting costs by very large amounts. Called efficiency and productivity improvements.

The Integrated Care System “knobs” are about how to enforce this financial discipline across all the NHS organisations in the whole Sustainability and Transformation Plan area. This is to be carried out through the Integrated Care System Partnership Board and Primary Care Network contracts.

The knobs include:

A system-wide financial control total where the Integrated Care System Partnership Board – a body with no statutory existence or powers – nonetheless:

“oversees financial resources of NHS partners within a shared financial framework…and … maximises the system-wide efficiencies necessary to manage within this…budget”

Source: West Yorkshire and Harrogate Integrated Care System Partnership Board’s Terms of Reference, 4 June 2019

Aligned local authority financial planning and performance – although not subject to the NHS financial control total and its risk management arrangements.

BUT: there is to be shared local authority and NHS commissioning, service delivery, investment and decision making. This includes GP federations, primary care networks, specialist community service providers, Voluntary and Community Sector organisations, housing associations, community pharmacies, dentists, optometrists & private health and social care companies including care homes. Together, these make up so-called “place-based” Integrated Care Systems.

There are 7 of these in the West Yorkshire and Harrogate Integrated Care System.

Within these 7 place-based Integrated Care Systems, there are around 50 Primary Care Networks/Primary Care Homes. 5 of the Primary Care Networks are in the Calderdale Integrated Care System.

(Think of Russian matryoshka dolls that fit inside each other. It’s not an exact analogy though, because inside the biggest doll – the regional Integrated Care System – there’s a number of “place based” integrated care system dolls. And within each of these medium-sized dolls, there’s a number of Primary Care Networks – the littlest dolls.,)

A focus on population health management, through the Integrated Care System’s primary care networks, and aggregating this into “managing the totality of population health”.

Population health management is what Accountable Care Organisations (and now Integrated Care Systems) are “accountable” for.

They are accountable in the sense that this is what they get paid for, through incentives in the payment and contracting processes for Primary Care Networks and for so-called “place based” Integrated Care Systems – more below in the Primary Care Networks section.

The aim of Population Health Management is to reduce unplanned hospital admissions, along with the so-called modern epidemics such as diabetes, cardiovascular and respiratory disease, that cause many people to end up in hospital.

No one could argue with this intention. But Population Health Management inappropriately blames the host of “preventable” illnesses on people’s lifestyle choices.

It ignores the fact that so-called modern epidemics result from environmental, social and economic injustices outside individuals’ control – including successive governments’ cruel, economically illiterate “austerity” policy that’s associated with 120,000 deaths between 2010 and 2017.

Instead of properly funded public health services and a wider “health in all policies” approach that tackles the environmental, social and economic causes of ill-health, Accountable Care requires people who suffer from – or are judged to be at risk of – preventable illnesses to take part in what Calderdale Clinical Commissioning Group’s Accountable Officer calls:

“industrial scale behaviour change schemes.”

He has also said that this means

“moving away from the dependency model of healthcare”.

Risk stratification of the population and surveillance medicine

In order to do this, Population Health Management requires the segmentation of the population of each Primary Care Network into groups that are at different levels of risk of illness and unplanned hospital admission.

Those most at risk are put into so-called virtual wards where they are subject to remote monitoring by various digital devices and provided with what is deemed the most appropriate healthcare.

This segmentation or risk stratification of the population relies on the analysis of the whole population’s patient medical records, using analytics software provided by private companies, notably Optum.

This amounts to surveillance medicine and apart from anything else looks like a civil liberties nightmare – as well as a massive source of profit for global companies eager to get their hands on our data. It monetises our bodies as data sources.

And it’s pushed forward through revolving door traffic between executives of NHS quangos and corporations that make use of this data.

Population health management also involves a lot of screening of patients predicted by data analysis to be at risk of illness.

This may or may not be ethically desirable or practically helpful. (Dr Margaret McCartney, GP and author of The State of Medicine, has done a lot of work on the uselessness, inappropriateness and opportunity cost of many mass screening schemes.)

Powers of regulation, oversight and assurance devolved from the now-merged NHS England and NHS Improvement.

This Integrated Care System “knob” is huge. These powers will be executed by a Integrated Care System Oversight and Assurance Group. By what authority does it have the right to do this? Integrated Care Systems have no statutory existence or powers, so are effectively unaccountable. (Oh, the irony.)

The West Yorkshire and Harrogate Integrated Care System Partnership Board Memorandum Of Understanding shows that these powers include:

  • making recommendations on recovery plans for NHS organisations that are in “deficit”
  • appointing a turnaround Director/team and
  • restrictions of access to discretionary funding and financial incentives.

The overall intention is to cut costs and restrict patients’ use of the NHS – while making the unaccountable Integrated Care Systems responsible for doing this, not the NHS quangos.

As an example of discretionary funding and financial incentives, Calderdale and Huddersfield NHS Foundation Trust has this year accepted its financial control total. (Last year it refused to).

On top of 5 years of savage so-called “efficiency cuts” to the hospitals’ spending, this financial year the hospitals trust must make further “efficiency” cuts of £11m, in order to reduce the deficit from £43.1m in 2018/19 to £9.7m in 2019/20. (In reality, what they call the ‘deficit’ is a funding shortfall.)

These financial plans depend on the hospitals trust meeting the 2019/20 control total of £37.9m. If it doesn’t do this, it will lose £28.2m of funding. To meet this control total, the revised Strategic Outline Case says transformation of services is essential.

This transformation of services amounts to dismantling the trusts’ 2 District General Hospitals, each with full 24/7 blue light A&Es, into one acute and emergency hospital for the whole population of both hospitals’ areas, and one small planned care clinic also for the whole population of both areas, plus a glorified urgent care walk in centre, albeit with resuscitation facilities and consultant cover.

NONE of these “knobs” are being scrutinised by the West Yorkshire and Harrogate Integrated Care System Scrutiny Committee.

Scrutiny powers for Integrated Care Systems are sorely lacking, because the Secretary Of State has not taken action on the Independent Reconfiguratio Panel’s recommendation that they issue Sustainability and Transformation Plan scrutiny guidelines. The Is Anyone Listening? campaign is about this and a public law firm has asked the campaign for information.

Integrated Care Systems also come with a number of laudable sounding other goals, of course.

The West Yorkshire and Harrogate Integrated Care System Board says,

“Most importantly, we are…

  • Working to improve people’s health
  • Working to improve people’s experience of health and care
  • Making every penny in the pound count so we offer best value to the taxpayer
  • Making the most of valuable staff, their skills and expertise
  • Through a true partnership that works with people.”

(Source: last page of item 4/19 of West Yorkshire and Harrogate Integrated Care System Board meeting 4.6.19)

We need to keep demanding evidence that these goals are being met.

Because the Integrated Care Systems are entirely continuous with the Sustainability and Transformation Plan agenda of Slash, Trash and Privatise.This is pretty incompatible with improving people’s health and providing decent working terms and conditions for NHS frontline staff.

Primary Care Networks – the “neighbourhood” building blocks of Integrated Care Systems

NHS England and the British Medical Association define a Primary Care Network as:

“GP practice(s) (and other providers – eg community (including community pharmacy, dentistry, optometry), voluntary, secondary care providers and social care) serving an identified ‘Network Area’ with a minimum population of 30,000 people.”

(Source: Network Contract Directed Enhanced Service Contract specification 2019/20 April 2019. Para 3.2 and footnote 6, p10)

This collaboration between GPs and other providers

“will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated…”

(para 3.6)

Each Primary Care Network is led by a Clinical Director, who is key to making sure that Primary Care Networks carry out Integrated Care System plans:

“The [Primary Care Network] Clinical Director will work collaboratively with Clinical Directors from other PCNs within the ICS/STP area, playing a critical role in shaping and supporting their ICS/STP, helping to ensure full engagement of primary care in developing and implementing local system plans…”

“They will represent the PCN at CCG-level clinical meetings and the ICS/STP, contributing to the strategy and wider work of the ICS/STP.”

(Source: Network Contract Directed Enhanced Service Contract specification 2019/20 April 2019. 4.4.2.c and 4.4.2 e

West Yorkshire and Harrogate Integrated Care System is based on about 50 Primary Care Networks.

One model for working as a Primary Care Network is the so-called Primary Care Home. (Meaning: the home of primary care – not a first care home.) This model has been adopted in a number of areas, including West Yorkshire. Primary Care Homes have also played a role in informing national Primary Care Network policy. They group together all the GP practices in a Primary Care Network, together with a range of other NHS, social care and voluntary and community services.

Hundreds of GP practices in England are already part of Primary Care Homes – others, such as the Upper Calder Valley Primary Care Network GP practices, still have to set up as a Primary Care Home.

5 Primary Care Networks are in Calderdale. Calderdale Clinical Comissioning Group’s Care Closer To Home Commissioning Prospectus states that these Primary Care Networks will be key to a new Integrated Care Alliance, and the likely end point of this Alliance is a contract which the Prospectus describes in terms identical to those that define the Integrated Care Provider contract. (See below for more about Integrated Care Providers.) Although it coyly avoids naming the contract as such.

Although the Primary Care Network Contract funding is not explicitly conditional on making fewer referrals, the contract contains an incentive for GPs to make fewer referrals. GPs are unlikely to ignore this incentive.

Other factors also create a strong likelihood that GP referrals to hospitals for many treatments will be a thing of the past: Primary Care Networks will have to comply with commissioner restrictions to growing numbers of elective care treatments.

The Primary Care Network contract nails down the shift of services out of hospitals into the “community”, that has been promoted in all Sustainability and Transformation Plans and NHS England’s 5 Year Forward View.

A further shift is out of community health services and primary care, into self care and self management.

These moves are called the “left shift”.

This “left shift” is intended to “empower” patients to increase their resilience and self-care and self manage their illnesses – which is what is meant by “ending the dependency model of healthcare.”

However there is another, hidden agenda: to shift the cost of health care onto the patient and their family

As ever, the Kings Fund is promoting all things to do with Accountable Care – in April 2019 they held a Population Health event:

The “left shift” involves the employment of around 22K auxiliary healthcare staff, via the Primary Care Network contract.

This contract brings extra money to employ additional social prescribing link workers and clinical pharmacists. (100% of the employment costs of extra link workers and 70% of the costs of clinical pharmacists.)

Of course these are trained professionals who can enhance the work of primary care teams – although the Primary Care Network subsidy of their wages is causing concern among some Advanced Nurse Practitioners that this will undercut their own jobs.

Another problem is that the Primary Care Network contract is not about employing these auxiliary staff to add value to the primary care team, but to substitute for GPs – an entirely different kettle of fish – and to increase the role of charities in the provision of health and social care services. The pace and scale is also a worry, as is the ratio of GPs to allied Health Professionals.

Still and all, Health Minister Seema Kennedy has said in a reply to a written question from Thelma Walker, MP for Colne Valley:

“The new Primary Care Network arrangements will not prevent patients seeing their preferred professional at their practice.”

We think this is spin. Increasingly, patients report being unable to get appointments with their GPs

As mentioned above, the Primary Care Network contract requires risk stratification of patients, in order to carry out population health management. (And the contract payments are tied to “population health outcomes.”)

As a consequence of risk stratification, GP consultations will most likely be limited to patients predicted to be most at risk of unplanned hospital admission (who form a very small percentage of the population), in order to prevent the need for their hospitalisation. This restriction to their work has been lamented on social media by GPs.

Integrated Care Providers (formerly called Accountable care organisations) are the final destination for Integrated Care Systems

They differ from Integrated Care Systems (which have no statutory existence or powers) by being a single, legal entity with responsibility for planning and providing the bulk of NHS (and possibly social care and public health services) in a given area area, through a very ten year large lead provider contract that it uses to subcontract everything it itself can’t provide.

In this way, Integrated Care Providers would reduce Clinical Commissioning Groups to very small strategic planning roles and hand most of their powers to the lead provider who holds the Integrated Care Provider contract. This will make for even less transparency and accountability than there is now.

The Integrated Care Provider contract was the subject of our Judicial Review last year, which failed when the Supreme Court refused our application to appeal. Stephen Hawking, Professor Allyson Pollock and others also mounted a Judical Review against the contract.

Integrated Care Providers will most likely be a new form of Trust – an Integrated Care Provider Trust, if NHS England’s proposed primary legislation is enacted to grease the wheels of the NHS Long Term Plan.

This won’t solve the problem that Integrated Care Providers would still operate through a rotten contract that aimed to cut costs and ‘manage demand’ for NHS care.

Accountable Care is not the kind of NHS that we need. We need an NHS where doctors and patients decide together on treatments face to face, based on clinical needs and patients’ values – not according to digital algorithms and financial considerations.

Accountable Care models are a cash cow for global digital technology and life sciences companies. They are nothing to do with social solidarity for the ill and infirm, which is what our NHS is and needs to remain as.

Instead, by splitting the NHS into 44 local health and social care systems or providers, and restricting patients’ access to many operations and treatments on the basis of financial considerations, they abandon the basic NHS principle of social fairness that comes from sharing the risks and costs of illness across the whole society – from rich to poor, from healthy to poorly, from urban to rural

Accountable Care – shrinking the NHS to a safety net service in a two tier health system where only those with dosh will get comprehensive health care

The experience of many people is that moves towards Accountable Care over the last decade have created a shrinking NHS with deteriorating standards – despite the best efforts of dedicated frontline NHS staff in all types of jobs.

It’s becoming clearer how this shrinkage would work. It doesn’t look good.

To us this all looks like a sly withdrawal from the core NHS principles of a universal, comprehensive health service that is free at the point of use and based on clinical need.

This is why are we resisting Accountable Care – whether Integrated Care Systems, their essential components the Primary Care Networks or Integrated Care Providers.

Because they undermine the principle of NHS4All. And in doing so:

  • They rely on Population Health Management which appears coercive and a nightmare from a civil liberties point of view: they treat our bodies as sources of data that global companies will get their hands on.
  • They encourage the neoliberal merger of public and corporate resources – ie corporate rip off of public assets.
  • They are a nightmare from the point of transparent, accountable and democratic governance.
  • They replace statutory NHS, social care and public health services with charities, voluntary organisations and community interest companies. Not only does this fragment services, these organisations are often economically precarious and likely to collapse or cut corners.

None of this has any democratic mandate – it is all based on the 2012 Health and Social Care Act, which was not in any party’s 2010 manifesto.

Of course the propaganda says otherwise. All is for the best in the best of all possible integrated care worlds.

It is very important that we pay attention to, document and publicise what we see happening – both to patients and staff. Does it bear out the propaganda claims? Or not?

Our NHS is being stolen from us. We’re going to get it back.

One comment

  1. In Kirklees, the social prescribers are recruited by the Kirklees Council. It is likely but not completely understood by the CCG as of 4 July 2019 to whom these social prescribers would report. The CCGs chose the council to do the recruiting because they already had a council social prescribing function, which they found out on 4th July is not working! It is an aspiration that the Social Prescribers will report to the PCNs, but where and how, has not been decided yet. It all seems a badly managed inefficient fiasco. Have the Scrutiny Committees examined this? I don’t expect so. The money started during the week of 4th July so the CCG hoped the Social Prescribers had been recruited! More work there for them to do I think.


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