Off Piste With the NHS

I can be a bit slow sometimes, but I think I've just woken up to the fact that the NHS is seriously under threat. Yes of course I've been aware of increases in 'contracting out' by the likes of the dreadful Richard Branson and his shit Virgin brand (and he's gone back to selling the bloody Daily Mail on East Coast Main Line), and he even sues the NHS when he doesn't win, but until yesterday, I'd never heard of Accountable Care Organisations. Go on, be honest, had you?

I'd even been vaguely aware that the amazing Stephen Hawking was taking the dreadful health secretary Jeremy Hunt to court, but I'm ashamed to say I hadn't clocked why exactly. I was surprised and disappointed when he suceeded in arguing the toss with Theresa May in order not only to keep his job, but expand it with responsibility for social care, but only now am I beginning to realise why. 

The Tories have a plan, a cunning plan and according to this comment seen on Facebook, the argy bargy with the junior doctors last year over a '7 day-a-week NHS' was a deliberate smokescreen for something much more sinister, Accountable Care Organisations. 

"It’s a mess. This has been a while coming and done by extreme stealth - conspiracy theories abound, not least that the junior docs strike was engineered to deflect from this. It’s privatisation by the back door and completely against the founding ethos of the NHS. We have one of the most efficient and inclusive health services in the world, even with all its problems, and it’s envied... instead, we will see a poor relation of the US model, with large tracts of the population unable (read “ineligible”) to receive care. And since yesterday, social care is going the same way."

So, what's going on? This Guardian article from November last year makes me feel a little better regarding my ignorance:-   

These little-known opaque bodies could run health services. Are they legal?

Unless you work in the NHS itself, or inhabit the health policy bubble of academics, thinktanks and staff groups, chances are the phrase “accountable care organisations” means little. If so, you would be forgiven for not knowing that ACOs, their acronym in NHS speak, and their close relation “accountable care systems”, are – in Simon Stevens’s view at least – the best way to save the health service from the otherwise unsquarable circle of rising demand and constrained funding.

Under NHS England’s plans, ACOs are supposed to bring together providers and commissioners of health and social care services who will then assume joint responsibility for the health of an entire area’s population. So far, eight areas have signed up to become ACOs although they are still only in nascent and shadow form. Stevens expects them to “deliver fast-track improvements”, such as fewer emergency hospitalisations and better care in people’s homes. Yet despite the scale of the change such a move envisages, so far ACOs have remained firmly under the radar, with minimal media coverage or public debate.

All that may be about to change, however. Two separate groups of NHS campaigners are taking legal action to challenge the legality of ACOs. One application for judicial review has been brought by Leigh Day, London-based lawyers with a track record of challenging NHS official decision-making, on behalf of 999 Call for the NHS, a grassroots NHS group.

999 Call claims that ACOs are “unlawful under current NHS legislation … because the new ACO contract does not link payment to the number of patients treated and/or the complexity of the medical treatment provided, as required by the 2012 Health and Social Care Act, but is based on a fixed budget for an area’s population.”

Those behind the other legal challenge include Allyson Pollock, a professor of public health at Newcastle University, BMA council member and long-time critic of PFI, NHS privatisation and reorganisations of the NHS in England. “We are seeking a judicial review to stop Jeremy Hunt and NHS England from introducing new commercial, non-NHS bodies to run health and social services without proper public consultation and without full parliamentary scrutiny,” she says.

ACOs are informal arrangements, which have no basis in law, yet are being lined up to be given extensive authority including, potentially, power over combined budgets for an area of billions of pounds. So, depending on how the court cases progress, each legal action presents a risk to NHS England and the Stevens modernisation project upon which his legacy and, much more importantly, the very future of the health service, depends. Why? Because everyone in the senior ranks of the NHS knows that, without new legislation to formalise their so-far informal role, ACOs could turn out to be a legal house of cards that one challenge could bring tumbling down.

But the lawsuits also offer the possibility that NHS England will at last be forced to explain and defend in public – and, crucially, prove the legal basis of – its plans.

Now is the time for health bosses to spell out exactly how ACOs are supposed to radically transform the NHS. They must make the case for why the loss of local services is worth it in pursuit of the bigger prize of better care and lower cost through more services outside hospitals, and fewer, regional centres offering specialist care.

That mission, involving unprecedented integration of health and social care, has widespread backing – notably from the government, which has fully embraced “the Stevens plan” as its health policy. But are ACOs, the chosen vehicles for delivering that, entirely legal? We may soon find out.

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This from the north-east sounds eminently sensible and forward-thinking. But many of us know that the NHS cannot be in safe hands if they are Tory, can they?  

Northumberland Accountable Care Organisation
The vanguard and the people it serves

The collective vision of health and social care partners in Northumberland is to create a system which consistently delivers the highest quality of care and a seamless patient experience for people living across the county.

This vision is supported by plans to develop a single accountable care organisation: this is an overarching organisation that sits above a joined up health and social care system made up of a number of different providers, from health services to the local council. The aim is to help teams across different organisations to work more effectively together, with the same shared goals.

The Northumberland Accountable Care Organisation partners are:
Northumbria Healthcare NHS Foundation Trust
Northumberland Clinical Commissioning Group
Northumberland County Council
North East Ambulance Service
Mental health services
Local GPs
Local patients
Health and Wellbeing Board
Healthwatch

The NHS organisations jointly serve a population of more than 320,000 people across Northumberland – one of the largest and most rural areas of England.

What is changing?

Urgent and emergency care has already been transformed, with the opening of the Northumbria Specialist Emergency Care Hospital in June 2015. This new hospital, the first purpose-built of its kind in England, provides specialist consultant-led care, seven days a week, for all serious emergencies. Urgent care centres for walk-in patients with less serious problems are now available 24/7 at general hospital sites.

Development is now focused on improving access to GP advice during the normal working week and exploring the potential for new networks of GP practices to work together to offer extended access, based on patient need, across the county.

To support this, new locality based multi-disciplinary teams are piloting new ways of working to proactively look after patients who are most vulnerable, as close to home as possible. This includes an acute home visiting service using pharmacists and the wider community nursing team to support GPs in managing home visit requests as well as working with colleagues from mental health and other specialists to proactively support people with long term health problems to stay healthy and well.

Key benefits

• Improved outcomes for seriously ill patients requiring emergency hospital care
• Increase same day access to GP advice and reduce out-of-hours activity
• Reduce reliance on emergency care and hospital admissions
• Create more time for GPs to plan and care for those with long term or complex needs
• Supports the future efficiency and financial stability of the health and social care system as a whole

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A bit of digging around on the internet quickly unearthed the following article from March 2016 on the Open Democracy website. It's far too long to republish in it's entirety, but well worth reading in full. To be honest it's shocking, not least as a demonstration of how blissfully ignorant I have been regarding something so important, but also how well-earned that 'nasty party' monika is and that was self-imposed by Theresa May on her party in an unguarded moment of honesty. 

'Accountable Care' - the American import that's the last thing England's NHS needs

A note from the editor: "It’s been a busy few weeks in transatlantic healthcare. Over here, Jeremy Hunt has imposed a junior doctor contract that’s likely to see doctors leave in droves, if he can force it through.

Meanwhile across the pond, would-be presidential candidates Hilary Clinton and Bernie Sanders have been slugging it out over healthcare in the democratic primaries. The left-wing Sanders’ calls for a ‘single payer’ system – more like our NHS – have highlighted just how far President Obama's healthcare reform fell short of providing an equitable healthcare system, thanks to ferocious lobbying by US health corporations.

And one man has played an interesting role in both situations.

NHS England boss Simon Stevens came out in full support of Hunt’s decision to impose the junior doctors' contract, to the dismay of many. His intervention has prompted some to look again at what else Stevens - recently dubbed ‘the fourth most powerful man in Britain’ – might have up his sleeve, or rather, have hidden in plain sight in the poorly understood ‘Five Year Plan’.

What’s known to surprisingly few is that before Cameron recruited him to run England’s NHS, Simon Stevens was a senior vice-president at US mega-firm UnitedHealth, with special responsibilities for lobbying both to water down ObamaCare, and to push for health to be included in the controversial TTIP transnational ‘trade’ deal.

In a series of linked articles, we explore NHS boss Simon Stevens’ plans for England’s NHS – and how we can make sense of them in the light of his US roles.

In this first article, we look at Stevens’ ‘big idea’ both at UnitedHealth and in his NHS 5 Year Plan - ‘new models of care’ – and show how these are market-based models that closely correlate to Accountable Care Organisations in the US."

‘Accountable Care Organisations’ – do they actually save any money?

In April last year various members of the Kings Fund published an article (in the BMJ) offering their usual cautious endorsement of market-based developments for the NHS. In this case it was for the new care models outlined in the Five Year Forward View, and in particular for those models – the Primary and Acute Care Systems (PACS) and Multispecialty Community Providers (MCPs) - which most closely correlate with emergent Accountable Care Organisations in the US.

As the article points out, the Forward View “explicitly acknowledges that primary and acute care systems are analogous to ACOs”, and, with health secretary Jeremy Hunt arguing that NHS reforms will lead to the development of ACO-like organisations in England, the Kings Fund authors ask what the NHS can learn from the experience in the US. But what they fail to mention, is that ACOs appear to be part of an overall strategy to frustrate the introduction of national health insurance in the US, and quite possibly to destroy it in England.

Unpacking the meaning of ACO development in both England and the US is rather problematic, especially given the technocratic tenor of debate, and the sheer complexity of US healthcare. In fact commentators have by and large refused to accredit US healthcare with the term ‘system’ owing to its fragmented nature, with a host of relationships between insurers, providers, employers, state and other federal sources, and individual consumers. Payment systems and organisational formats are similarly byzantine, and the picture is further compromised by armies of uninsured and underinsured.

However ACOs have been put forward as means of addressing at least some aspects of organisational fragmentation, soaring costs, and low quality outcomes. Initially developed to improve performance in the federally run Medicare programmes, the ACO concept has since expanded significantly and is now regarded as a cornerstone of the US healthcare reform agenda.

The basic concept of an ACO is that a group of healthcare firms agrees to take responsibility for providing care for a given population for a defined period of time under a contractual arrangement with a commissioner. ACO’s use a variety of market-based mechanisms to lower costs whilst achieving a set of pre-agreed quality outcomes. This is mainly accomplished by ‘aligning incentives’ between providers and commissioners, or in other words, sharing any budget savings between hospitals, doctors and the commissioning Medicare programme itself. For those ACOs contracting with private insurers any savings will be shared between the two organisations.

A close correlation exists between the scale of provider integration, the extent of risk assumption and the payment mechanisms used. ACOs may, for example, be given ‘bundled’ payments that cover all the care for a particular medical condition or treatment over a specified timeframe, Or they can get ‘capitated’ or ‘global’ payments, which are fixed payment to providers for all or most of the care that their patients may require over a contract period, such as a year, adjusted for severity of illness, and regardless of how many services are offered. The size of an ACO will on the whole dictate which payment option will be adopted: larger ones will have the scale and financial capability of adopting capitated payments which, although they mean offering more or less comprehensive care, involve greater financial reward.

Several different types of ACO exist. Stephen Shortell, one of the authors of the Kings Fund article and a key advocate of the ACO concept, identifies at least five, though the main ones are, pace the Forward View, the integrated delivery system, and multi-specialty group practices. Integrated delivery systems - essentially the Kaiser Permanente model - typically own hospitals and other facilities and also have at least one salaried multi-specialty group practice (generalists working alongside specialists in a primary care setting) and also own a health insurance plan. Multi-speciality group practices on the other hand may own a local hospital, or have strong affiliations with one, and may have contracts with several health insurers in their area.

Or at least that’s the theory. But even in their short time span ACOs have encountered several problems, according to the Journal of Health Politics, Policy and Law (August 2015), and while some projects are novel evidence suggests that efficiency and qualitative gains have been negligible.

Far from saving money the various Medicare ACO programmes have seen increased costs, largely through the use of shared saving bonuses and subsidies for providers. None of the projected $320 million savings were achieved between 2011-2014 – in fact the ACO programme actually COST Medicare an additional $3 million, according to a Kaiser Health Foundation report. The report also highlights how only a small (and shrinking) percentage of the ACOs really ‘share risk’ with Medicare – the vast majority, 334 out of 353, are eligible for bonuses but face no penalties for losses.

Similarly the incentives to create ACOs have led to greater consolidation of providers and to hospitals buying up physician practices, both of which lead to raised overall spending. Such consolidation has also raised concern that regionally dominant ACOs will use their market power to drive up costs with the likely encroachment of anti-trust laws.

‘Managed care’ – not managed in patient interests

Of perhaps more concern, especially for the NHS, is the extent to which ACOs, far from being transformative, are simply a faddish rebranding of existing for-profit structures – effectively, just Health Maintenance Organisations in drag - as commentators like Theo Marmor and Kip Sullivan have suggested. The question is far from semantic as HMOs are often seen as the most objectionable aspect of the US ‘system’, and certainly a primary cause of repeated clamour for reform.

HMOs can be considered as the key institutional expression of what’s known as ‘managed care’, deemed a corporate compromise between insurers and large employers to contain costs whilst also ensuring profits and disciplining the workforce.

Essentially HMOs act as financial intermediaries between customers and providers, collecting payments from the former and arranging their care with the latter. They do however come in various guises, distinguished primarily by the degree of integration between healthcare insurers – the financial intermediaries - and service delivery from hospitals and physicians, and using instruments such as capitated budgets, pre-authorisation and strict utilisation reviews to manage expenditure.

As leading critics of the model, Drs Himmelstein and Woolhandler, point out however the history of HMOs isn’t exactly edifying, and includes routine denial of patients’ access to medically necessary treatment, fighting claims, screening out the sick, paying exorbitant CEO salaries, and undertaking systemic fraud. And all while offering what is effectively low rent medical care with considerable hidden costs in the forms of top-ups and deductibles.

Whilst HMOs are primarily dominated by large corporate insurers, ACOs are put forward as being led by providers – and by friendly local healthcare providers, at that. Advocates of this argument, such as Ezekiel Emanuel, a key architect of Obama’s Patient Protection and Affordable Care Act (ACA), went so far as to say that ACOs would soon make the big health insurance companies redundant.

However within a year of the ACA consultants Booz & Co (now part of PwC) reported that “virtually every major payor (insurer) is either involved in, planning, or seriously considering ACOs. Many health plans are actively helping providers, especially integrated systems and primary care physician (PCP) groups, to form ACOs… some of these projects are more ambitious, while others are simple re-brandings of existing constructs”.

Like Shortell, Booz describe differing ACOs and how the insurance industry – companies like Aetna, UnitedHealth, Humana and Blue Cross - are taking a leading role in developing the model. Such activities include offering shared savings to clinicians, to analysing data and assessing how risky patients are before they’re accepted as eligible for that ACO’s plan. They also offer ACOs disease management programmes and an already established customer base. By 2013 UnitedHealth, for example, were able to report that accountable care currently accounts for more than $20 billion of the company’s reimbursements to providers, and the insurer says it expects that number to more than double to $50 billion by 2017 as it contracts with additional ACOs.

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