It’s an Alphabetti Spaghetti of Acronyms

The NHS has been broken up into 44 Sustainability and Transformation Partnerships. Each STP area is called a footprint. In each footprint NHS hospitals, Local Authorities, private healthcare companies and voluntary organisations have been asked to work together to form Accountable Care Systems (ACS). An ACS was, until the 2 February, a new name for an STP but with a formal agreement called a Memorandum of Understanding between all the partners. It doesn’t change their legal responsibilities so they can be created without changes in the law.

Here’s how one of these footprints describes itself in its Memorandum of Understanding, “As we are in transition it is helpful to clarify how we use terminology and acronyms for the purpose of this document. Sustainability and Transformation Plan (STP), Accountable Care System (ACS) and South Yorkshire and Bassetlaw Health and Care Partnership (SYB) are used throughout and they refer to the same thing – our SYB Partnership.”

Now they are going to have to add a new acronym and re-do all their documents. According to the HSJ (Health Service Journal) on 2 February, “NHS England has rebranded accountable care systems as integrated care systems, and said they will replace sustainability and transformation partnerships. Planning guidance for 2018-19 from NHS England and NHS Improvement today said ICS will now be the “collective term” for the devolved health and care systems in Greater Manchester and Surrey Heartlands, as well as the eight shadow accountable care systems. It follows controversy about the term “accountable care”.” (no link, paywall)

So ‘Integrated Care System’ or ‘Integrated Care Organisation’ is exactly the same as ‘Accountable Care System’ or ‘Accountable Care Organisation’ so we will refer to Integrated Care from now on.

Either way it is describing a different way of organising the NHS which is based on how Medicare is provided in the US. US healthcare firms have helped design it and are advising on how to make the changes. They even use the term ‘Integrated Care’ as well as ‘Accountable Care’. So the ‘controversy’ that prompted the name change won’t disappear, because the problem is far bigger than a name.

Maybe all the people involved in the drawing up of the documents will revolt against yet another name and by tomorrow it will be changed back again!

Working together sounds good, doesn’t it?

Each footprint can decide how they provide health and social care as long as it fits with NHS England’s ‘new models of care’ which base services around a central hub. And they have to stick to strict financial rules called ‘control totals’. Up to now the NHS has worked through a network of GP practices, hospitals and community services. The services were designed to be accessible to the patient. Care was placed near the patient. The new models of care will mean that the patient may well have to travel to the service. It is very different from how care has been provided for the last 70 years.

But what is an ICS? Do we need them for services to work together?

An Integrated Care system is based on centralised specialist hospitals (with A&E) networked with satellite urgent care and multi-speciality community providers (without A&E). They rely on ‘self-care’, volunteers, apps and lower-skilled professionals replacing doctors and nurses. They move hospital based activity into the community in conjunction with Local Authorities.

The system is designed to be run by a newly created commercial organisation which is called an Integrated Care Organisation. They are also called ‘accountable care’, ‘place-based’ or ‘horizontal and vertical integration’. They are all the same thing. The ICS is an agreement about the way they are organised but the ICO is who runs it. ICOs do change legal responsibilities and that’s why the law has to be amended to allow them.

8 STPs have already been lined up to become ICOs with a second lot due for approval by March 2018.

£Billion contracts up for grabs for public services.

Contracts to run ICOs are worth £billions and last 10-15 years.

Jeremy Hunt says he expects NHS organisations to win the contracts. But current legislation does not protect the public sector from private companies winning contracts for services. Not only can private companies bid for these contracts but they can sue if they are excluded.

NHS hospitals, in order to ‘stay in the market’ must compete for contracts. Many hospitals have formed companies thus increasing the number of private health companies competing in the healthcare market. It also blurs the lines between the public and private sector.

ICOs are designed to be the future of the NHS – they are not just an experiment.

But they are a mess of conflicting boundaries between GP lists and local authority boundaries – and that matters because that is how the funding will be allocated and working out which patient is whose responsibility is likely to be a bureaucratic and legal nightmare.

The eight pioneer ICOs are driving forward the new NHS without regard to consultation or public health. The 36 footprints that have not been considered for ICOs yet soon will be. Services will be lost. The NHS will continue to shrink.

Already a staggering £5.3bn a year is being transferred from the hospitals budget to care in the community without anything much to show for it.

You may well ask why this is happening.

We are told that the changes are necessary because we can’t afford the NHS. This is not true.

We are told there is no money: ‘the government has no money of its own’. This is not true.

We are told we need to pay more taxes to keep the NHS running. This is not true.

Politicians suggest that National Insurance contributions or adding a penny on to tax can pay for the NHS. This is called a hypothecated tax. Linking specific taxes to specific services is the first step on the road to creating insurance.  The NHS is the only service we are ever asked to do this for.

In 2008, in the face of a fiscal crisis, the government pumped money into the economy. It was a political choice. It didn’t increase taxes or put an extra penny onto income tax. This is because the government can increase the amount of money to keep the economy running. It adds money, it doesn’t take it from anywhere else. When the government bailed out the banks, they didn’t drain the economy. Starving public services has done.

The NHS running properly keeps the economy healthy. It should never be de-funded to the point of collapse – ever. We can afford it.

Increased funding and fighting local closures in themselves won’t change what’s going on. This is the biggest attack on the NHS since it was created and it’s been through a few.

However, there are some silver linings and we have put together some ideas for what you can do.

What you can do nationally

** STOP PRESS** On Tuesday 6 February Jonathon Ashworth, Shadow Secretary of State for Health in the House of Commons, asked about concerns about the potential role of the private sector in ‘Accountable Care Organisations’. He tweeted afterwards, ‘Following pressure of campaigners and ourselves, ministers have now been forced to delay the regulations’. The confirmation from the government side came from health minister Caroline Dinenage. 

Make sure there is no legislation before consultation. 

  • Jeremy Hunt has been forced to agree to a national consultation on the formation of ICOs and ICSs. However, he says the implementation and legislative changes will go ahead before the consultation is complete.
  • Write to your MP and ask them to support campaigners and the Health Select Committee who say that the introduction of ICSs and ICOs should be halted until the consultation is complete. Consultation must come before the change in law, not after.

Early Day Motion 660 asks the government to put the creation of ICOs to full parliamentary scrutiny and debate before any legal changes.

  • Make sure your MP signs it. An EDM is like a petition, but it is only signed by MPs, not by the public. It is not a statement of whether they support ICOs. It is a statement that they believe that parliament must debate it – that’s democracy.
What you can do locally
  • Get as many people involved in local consultations for the STP footprints, ICSs and ICOs as possible.
  • Push your STP leaders and CCGs to use local media (newspapers, tv, radio) to inform people about the consultation.
  • Ask Local Authorities to use local publications to publicise the consultation meetings as broadly and as loudly as possible. Households, schools, pensioners groups, religious organisations, tenants and residents’ groups and campaigners must be informed and included.
  • Insist that documents are written in plain English. The proposals must clearly state where potential closures and downgrades might take place.
  • There should always be at least one speaker who champions the NHS as a public service and has an understanding of how the ICS model undermines this. If there isn’t then write to your local paper and say you want to know options, not be faced with a done deal
  • Complain if ‘consultation’ documents look more like adverts for the new system.
  • Write to your local councillors to ask them to say no to the changes.
Make sure you work together
  • Join a local campaign group – Keep Our NHS Public, Protect Our NHS, Save Our Services, Defend our NHS, Pensioners against the Cuts or similar.
  • If you are already in one suggest that you link up with any others you can find in your area. You may have different priorities and preferences – but you can work on local issues and national ones.

Spread the word – and respond to the consultation as groups and as individuals.

Want a full technical explanation of these legal and organisational changes? Prof Allyson Pollock has just published this in the BMJ. (available for 10 days free to view)

Want more background of where these ideas come from? Read our full briefing here.