Thoughts on ACOs/ACSs by Kay Ecclestone

I spent this afternoon researching for the new page of links to information about Accountable Care Organisations, what Cornwall Council are planning and what are the concerns or benefits of this.  I wanted to find out more so that I could respond by Wednesday 17th January to the Accountable Care System Inquiry via  healthcommittee@cornwall.gov.uk.

What have I found out?
I want to make clear from the start that these are just my views and my interpretation of the reports and articles that I have read.

1. The idea of a ACO or ACS is to have a cohesive, holistic system of care for a given population managed by one organisation.  

• This sounds brilliant doesn't it?  Lots of joined up thinking, one organisation looking after an individual person's health through the primary care system, into hospital and out into their homes, probably some cost saving as a reduction in duplication - what is there to object to?  
  • ​For this to work, "Every ACO needs to adapt to the history of local collaboration and the willingness of partner organisations to find common cause. Progress is likely to be made more quickly in areas where organisational arrangements are relatively simple and more slowly where they are complex." and "These challenges are not insurmountable but they take time to overcome. Hardly surprising therefore that areas with a history of seeking to integrate services, such as Northumbria and Salford, are furthest ahead in establishing ACOs in England. Yet even in these areas, progress has not been straightforward, confirming the view expressed in the Next steps document that it will take time for these nascent arrangements to develop and mature." (Kings Fund).  The Kings Fund describes itself as an independent charity but I wouldn't ever refer to as an organisation with socialist views.
  • Unfortunately the theme that runs through the report into the Quality Care Commission's report "Responding to a risk or priority in an area - Partnership working to deliver health and social care in Cornwall" is of a history where this co-operation hasn't happened and where there is "history of frequent changes in leaders, resulting in less well-developed relationships." (QCS, p.29) and "This report has identified that the components of the health and social care system in Cornwall are not working well together." (QCS, p.30)
  • Although it is called accountable, it seems to be the one thing that it isn't.  Who is it accountable to?  Who controls it?  There are judicial reviews challenging the proposed existence of ACOs.  Will current NHS minimum standards apply?
  • Will it open the doors for privatisation?  The fact that the idea originated in the US seems to make this more likely not less.  The more I read about our NHS, the more I realise how much is already privatised or "out-sourced".
  • Social Care is means-tested,  Health care is free at the point of delivery (we pay for it with our National Insurance contributions).  How will these two statements be reconciled?  It seems unlikely that Cornish Social Care become free at the point of delivery to all.

2. Why is Cornwall thinking of doing this and why now?

• Supposedly this is what we all wanted when we were consulted with as part of the Sustainability & Transformation Plan.  
  • The disadvantage of this is that the consultation was inadequate ("seriously flawed")and the survey biased by lack of information and insufficient options (who was going to disagree with these statements: "People told us that preventing ill health, more joined up care in the community and better access to GPs and urgent care services in the evenings and at weekends are the top priorities" )
• ​Well, apparently the Government is offering to write-off the £100 million debt that Cornwall theoretically owes the Treasury if we sign up to the ACO/S
• We were told as part of the Sustainabilty & Transformation Plan that Cornwall NHS services need to save £277m over the next 4 year

So what do I think & what am I going to do?
I think, despite all the articles & opinions that I have read, that I still don't understand all the implications of this.  However, despite that, I know that I am not in favour of it.  My reasons for that decision are:

• The public consultation of the original STP was not fit for purpose and the survey was biased and would not have been considered valid for either of my Masters degree research projects.  This isn't just my view, for more details see Social Policy Research for Cornwall
• Being naturally suspicious, I suspect things that are being rushed through Council without full details - I read a great quote for a councillor that admits they don't fully understand it and haven't the detail to answer questions on it!
• I am very wary of things that need what looks to be a bribe from Government - if they can write off £100m debt for the creation of an ACO, then why can't they write it off to help Cornwall NHS anyway?
• Being cynical, I suspect things where there are sudden changes of name - the Cornish version of the Sustainability & Transformation Plan was called "Shaping our Future" (because STP got a bad name on social media?) and now we have moved for ACO to ACS (literally over the last few weeks), again because they want to distance themselves from the bad press of ACOs or from the results of a judicial review?
• I am worried about the fact that Cornwall’s own H&ASC Scrutiny Committee noted “significant financial risks” involved in actioning an ACO in Cornwall.
• Ben Bradshaw confirmed that I have made the right decision as he has just annouced that Cornwall should be embracing this - which as he "championed a greater role for private management of NHS Trusts" when he was Health Minister under Blair combined with the fact that I have never knowingly agreed with BB, helped to convince me that this wasn't something I wanted to "embrace"
• Considering all the information, however, I am not in favour of it primarily because there is to be a judicial review backed by doctors and by Stephen Hawking all of whom know far more about this than I do

So here is the text of my e-mail to  healthcommittee@cornwall.gov.uk (with thanks to North Cornwall Labour Party for much of the wording)
I am contacting the committee to voice my concerns and to seek answers to the following issues:
My concerns:

• that Accountable Care Organisations (ACOs) are being introduced without adequate public involvement or consultation; and implemented beyond any legal framework, creating problems of governance and accountability
• that there is no robust evidence base to support their use in the context of the English NHS
• that there is at least one judicial review proceeding and it seems premature to take action in Cornwall until the results of this are known

My questions:

• Can the committee guarantee that experienced clinicians would not be replaced with new lower-skilled and lower-paid roles, and that the NHS terms and conditions of employment would not be undermined?
  • ​What checks will be put in place to ensure that this cannot happen?
• What are the benefits of existing multiple procurements being replaced by a single, major, long-term contract to provide health and social care services for Cornwall?
• Is it true that the draft model contract for ACOs published by NHSE allows for, and is likely to attract, bids from multinational corporations?
• What will stop private companies from asset-stripping the NHS land and buildings?

I also intend to email Steve Double asking the same questions but also asking that he raise the issues of accountabilty in a debate in Parliament.
Kay Ecclestone