Well. Apologies. I thought I was up-to-date with all the structures and new developments in the NHS.  And I’m absolutely not.  Thing is, I realise now why Jeremy Hunt did his utmost to persuade Theresa May that he should not being moved on as Secretary of State for Health, and must remain as Secretary of Health and Social Care.

And what did I say about we didn’t want a new Secretary of State who would begin yet another re-organisation?  Better the devil you know?  Geez and – sigh! That man Hunt is on a mission, and there is yet another very profound NHS re-organisation going on right now. This is about ACOs or Accountable Care Organisations.  Have you heard of them? Yes? Good, you’re way ahead of me. No? Well they’re happening.  OK. Now, in Facebook a meme is going round on these structures, which actually I think I’ll just step back from a bit, as I don’t know where the instigator/s of said Facebook post have got their facts.

What is happening is this:

  • Accountable care is the latest buzz phrase (of which I was not aware)
  • It is a way for different organisations from both health and social care to work together (good)
  • It is a shift away from competition and a move towards a collaboration of and between very different and separate organisations like GPs, hospitals and the local authority (same thing but all good then)
  • The language of accountable care comes from the States (oh)
  • Does that mean that this is the way to bring in more privatisation and/or an insurance based health service (a key question)
  • Apparently, no, as these English versions of accountable care will be tax funded (OK)
  • There are currently 10 areas across England currently setting up Accountable Care Systems leading to ACOs (oh, OK, right)

The thing is when boundaries between health and social care are dissolved and these new structures are created (called Accountable Care Organisations) we should ask what powers will these ACOs have?  And who will they be accountable to? Some views are that these ACOs would permit commercial non-NHS bodies to run health and social services.  And when they do, note their provision to us will be governed by commercial contracts not government statutes.

So, is this bureaucracy gone mad, yes?  No, sadly this is the way of the world. You think improving the NHS would be to get rid of bureaucrats?  Sorry, we have moved into a complex world of procurement around the provision of health services.  Anyway, stepping aside from hyperbole, after a quick scout round there is the King’s Fund (a very high-profile think tank that has a good and balanced reputation) who says it doesn’t mean a larger role for private providers, and others like senior health professionals and campaigners who are arguing for a judicial review on these proposals, because they think it does.

Whatever.  Just note that this is an extension of the contract culture that I wrote about in my last post. Remember Carillon?  (Do have a look at this link as it takes you to the healthcare part of their website.) We will face the danger of commercial entities bidding for contracts that could fail because they undercut to get that contract. What a way to run a public service!

What do I want people to do?  The reason I write here is about grasping and grappling with what is going on out there.  We have to know, we have a duty to know.  We have to wake up, and we must understand the consequences of government actions.  I’m telling you before it is too late for the NHS that we must get rid of this government. (And I know the General Election is some way off, but just be aware) Because it is nearly, as in almost, too late to save the NHS.  Why?  Because the cost of bringing services back in-house will be exorbitant because compensation will be governed by commercial laws. So, if we don’t push and resist, and people like Hunt remain unchecked, there will not be an NHS as we know it.  Yes, it might be free for a while, but behind closed doors there is a continuous move towards private companies (that can only have profit in mind, because that is what they do) providing health care. And I cannot emphasise enough that this means their obligations to patients are and will be constrained and limited to commercial considerations. There will still be great doctors and wonderful nurses but if commercial companies under-cut too much and get into debt and walk away (it’s happened) who will pick up the bill, and the care?

And can I ask? What will actually change?  It is so easy for people at the top to agree to work together.  I’ve seen so many variations of committees run for and by top managers of health and social services who say we need to work more closely together. Middle managers are then tasked to start the process – but on the ground, where patients actually live – do you see what I mean? What happens? Yes, how will Accountable Care Organisations work when the frail and ill, and older people begin to get their multiple morbidities?  Management of change is easy at the top, but, in reality who will look after people in the community – poorly paid carers?  And where is the private sector in all this?  I am asking what do all those words mean, and where will that humungous effort to change our health care systems to ACOs end up?   The key question is what will be the outcome of this change?  Better care?  One would hope so. Or is it all about cheaper more commercialised care?

So, watch this space and be aware of, and beware silkily-spoken words about new arrangements for health and social care.

Penny Kocher 20th January 2018

Also see a seven step guide to accountable care – click here

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9 thoughts on “How to save the NHS – a quick up-date on Accountable Care Organisations

  • 20th January 2018 at 13:14

    Thank you for this and your last post, Penny. As a 71year old I find this quite scary. I find it hard to comprehend that with all their advisors previous governments did not see an impending crisis in funding. But of course no political party would increase National Insurance contributions for fear of losing the vote! I would happily have paid what was required of me for our wonderful NHS to have continued to be as efficient as it once was…………..but that is all in the past. I now have no faith in any politician or political party.

    • 21st January 2018 at 16:30

      I think that there won’t be all that much change for patients, apart from perhaps finding it even more difficult to see their GP and/or get referrals to consultants. However, A&E waiting times, planned operations and the pressure on beds should improve a bit as we move out of winter. But behind the scenes this government and their right-wing policy wonks are letting in more and more private providers – all quite legally. Also I think the lack of debate around the need for good social care and how we pay for it is so short-sighted. And I believe that there have been some surveys showing that the UK population would pay more National Insurance/Tax for the NHS. Ah yes, who do we trust? Politicians or the people who work in the NHS? On balance I think Labour aims to halt the march to privatisation. But whether they can is another matter, especially with contracts locked into commercial law – that’s the key thing. Can provision be brought back in-house – I’m just not sure about that. We have to watch that space!

    • 21st January 2018 at 16:34

      Ah yes, marches. I did so many when I was younger, mainly for CND. Honestly, I’ll leave the 3rd Feb to people who are younger than me! And I’m still recovering from that 3-week cold! What I can do, though, is assimilate jargon-laden information on policy and re-write it simply. That’s my contribution, I think 🙂

  • 21st January 2018 at 15:19

    Hi Penny
    from Berkeley California- way on the other side of the pond.
    I am a primary care physician practicing near here.
    Good for the March for the NHS! ( I marched yesterday for the Women’s March and fervidly hope and believe that the energy there will translate to a significant change in our Congress this fall.)
    Re your NHS issue in Great Britain:
    Great Britain spends approximately 9.7 % of Gross Domestic Product on health care, including your private insurances. The United States: 17.9%! And a very significant minority have no health care or expensive health care. (the moral compass of Republicans is unbelievable)
    Your NHS covers every citizen; ours does not. Your NHS gets far better scores for everything that matters in health care; ours is down –depending on the survey around 10-20th for any measure.

    Regarding the “Accountable Care Organization”–be cautious about what politicians promise.
    Affordability is not an issue for your situation: all citizens covered at no immediate cost to themselves–and a huge savings in terms of the overhead of billing! I say no immediate cost, because someone does pay the taxes that cover the system. Here “Accountable Care Organizations came into being early 90’s.
    They receive Federal dollars for Medicare (our “insurance” for providing over -65 people with medical care) sent to either for profit insurance organizations or non profit insurance organizations who then send the money to organized groups of MD/Hospitals/very large health systems. The largest not for profit such system in our country is Kaiser, and they make the MOST money from that transfer of dollars, and the for profit insurance companies: United, Aetna, Humana etc make also the MOST profit from these Federal Medicare dollars sent to these medical insurance companies.
    How do they do this? There is some waste in the system but they ring in all the patients who
    sign up and have them see specialists within the organized system. Which means that
    a patient who signs up here with me can’t go to University of California, San Francisco-a tertiary care center- just at the drop of a hat for their routine hip replacement, without an authorization.
    no one withholds care: a patient of mine with a very serious head and neck cancer has received
    superb treatment from UCSF through his HMO -Health Maintenance Organization -similar to an ACO but for a younger person.
    Remember the “all mighty dollar” : It informs the decisions made by the various bureaucracies
    involved in these decisions. Some of the waste is wrung out: for example getting an MRI authorization is made more difficult and sometimes that is a good thing.
    There are good things and bad things about the “ACO’s” but remember they all have a PROFIT bottom line. And will add to bureaucracy —
    Although as we age, more medical issues happen–and increasing numbers of treatments that did not exist >30 years ago when I did my training. I am a left wing progressive when it comes to covering every citizen in my country and have extensive ideas about how to do it but also recognize that there is an expense to this. Also those who make more should pay more. (don’t get me started on ACA -Obamacare)
    The reality is that your system has issues but in fact, probably needs tweaking, not massive overhaul.
    A brilliant book to read from about 8 or so years ago:
    “The Healing of America” by TR Reid
    about how systems were put in place around the world to pay for health care in first world countries.
    He gives the economic history of health care systems: but has a very funny last chapter
    set at an Ayurvedic center in India with regard to his chronic shoulder pain!

    Love both your blogs–love fabric and textiles, and hope someday to meet you!
    Mary Sears MD

    • 23rd January 2018 at 10:30

      Hello Mary
      Yes, our NHS is far more cost-effective than other health services, but you wouldn’t think so when you read our UK media, which does seem to aim to find all the disasters it possibly can. I asked my GP (saw her just now for a minor ailment and booked it 2 weeks ago) what the ‘winter pressures’ were like this year and she said no different to last year. Mind you they’re a very efficient practice as they triage their patients if they want to be seen that day – which is a good system. But last night the BBC showed a really ghastly example of an overwhelmed A&E. That’s partly where more money is needed, as in, there need to be more doctors on duty. However, the 10-minute programme showed an awful lot of older people amongst those waiting in ambulances and in corridors, and that’s what needs to be tackled. How do we age? How do we manage older people with multiple morbidities? Could their chest infections be managed in the community somehow, rather than turning up in A&E???? It seems there’s never any debate about staying healthy as you age, which is so short-sighted. And most of the many articles on our ageing population seem to take the stances, ‘what can we do for these poor sick old people, which is patronising as hell!

      As for those new arrangements for health and social care. Seriously, we want health and social care to work together, that’s good practice, but the profit factor is creeping into the NHS more and more with accompanying commercial contracts, which are the killer. So very, very short-sighted and yes, ideological on the part of our right-wing politicians, one of whom is banging on this very minute about the NHS needing £100 million a week extra. That’s our foreign secretary Boris and that’s find and dandy, but he’s doing it just to make a noise and is not to be trusted one iota. I will look out that book. Currently I’m reading Howard Zinn’s A People’s History of the United States, which is an amazing read, you’ve probably come across it!

      It’s been great to hear from you.

  • 22nd January 2018 at 19:45

    Thank you for your blog. I believe it’s even worse. The reason Hunt is not putting much needed emergency money into the NHS is because he’s waiting for these ACO’s to be set up so that contracts can be let to the private sector. The Tory ideology is that the private sector is always better than the public sector. An added bonus for the Tories is that their friends and donors can be rewarded with the profits to be made out of essential services. You would think that the collapse of Carillion would give them pause for thought. The fact that it hasn’t shows how virulent their ideology is. And of course, there’s always the good old taxpayer – you and me – to provide a safety net We underestimate the depths of the Tory evil at our peril.

    • 23rd January 2018 at 10:36

      No one on the right seems to learn, or want to learn, from the collapse and/or the bad practice of private provision. It’s totally ideological and based on moving a beloved institution paid for by taxes to the private sector which is obviously all about profit. I mean, we all have to change and I accept that, but what’s happening is outrageous.

  • 24th January 2018 at 14:43

    Hi Penny, thank you for all the research and reading that you do in order to help us to understand what it going on, or might be going on soon. How can we persuade the Govt. (of any stripe), that actually we would prefer to pay a bit more in taxes than have to rely on private companies who may, or may not, provide a decent service….


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