…. and then ISC” as 5-year Kennally Care business plan gambles on prevention rather than cure
12th February 2018
By Graham Smith
The change of Cornwall’s ambition to create an Accountable Care “Organisation” to an Accountable Care “System” instead was caused by NHS England simply changing the names, according to a Freedom of Information answer provided by council and health bosses.
The FOI answer provides the greatest level of detail so far about how the term “Accountable Care Organisation,” (ACO) used in December 2016, was a few months later changed to Accountable Care System (ACS) just as Cornwall tried unsuccessfully to be a “first wave” in a restructured NHS. The terms are controversial because draft ACO contracts explicitly embrace the potential for greater private sector involvement in the NHS.
But crucially, the FOI answer fails to detail any changes in the outline business case, fuelling suspicions that the two acronyms are interchangeable – as claimed by the King’s Fund think tank. According to the draft business plan, both ACO and ACS rely on a single, integrated, place-based capitated budget fixed for five years with a single strategic commissioner deciding where to spend the cash.
This differs from the current model of NHS funding in Cornwall in several ways, but of most alarm to protestors is the unanswered question about what happens if the money runs out before the end of the fifth year. At the moment, NHS organisations in Cornwall rack up mounting levels of theoretical “debt” due to what some local MPs accept is underfunding, and the spiralling costs of an ageing population.
The FOI answer says there was no deliberate attempt to mislead when the acronym changed from ACO to ACS. But in November, NHS England published draft contracts which implied that the whole of Cornwall’s health service could be outsourced to the private sector if it embraced an ACO.
This led council and health chiefs to claim that they “currently have no plans for an ACO.” In fact, the draft business case, which is for an ACS, does not exclude the possibility of outsourcing anyway. It advocates: “an acceleration of the review of financial Market Forces Factor for providers.”
The draft business case, which will be considered by the council’s cabinet next month, has still not been updated despite the further change of name to an Integrated Care System (ICS.) The plan gambles heavily on a “prevention better than cure” approach to reducing the costs of healthcare in Cornwall, advocating better eating, more exercise and a controversial approach to minimum alcohol pricing – but with no explanation of how any “Cornish border” controls could be enforced. The “prevention” part of the plan is designed to save £17 million a year.
Health campaigners say it is more important to study the detail of the business case than to be persuaded one way or the other by the constant change of acronyms. In the absence of a full business case and risk assessment, or draft ACS (or ICS) contracts, the draft business case in
A detail from the ACS outline business case which will go to Cornwall Council’s cabinet on 28th March. There are no details about how the proposal for minimum alcohol pricing in Cornwall could be enforced, as part of a £17 million savings target
Cornwall is still currently the most detailed guide to what health and council bosses are planning – yet it was not even part of the “evidence” considered by the widely ridiculed “Inquiry Panel” which last week persuaded councillors to vote unanimously in favour of proceeding with the ACS.
Cornwall’s GPs are now starting to make their voices heard, particularly within NHS Kernow. One GP told Cornwall Reports: “I have read the council’s outline business case three or four times and I’m very concerned. These days doctors have to read business cases all the time. It’s actually quite shocking that the Cornwall councillors who are pushing this ACS don’t actually know what they’re doing.
“Everyone is in favour of preventing ill health. But many of my patients are frail and elderly. They are mostly quite cheerful, but they are at that stage where they are thinking about funeral plans rather than Keep Fit classes.”
Cornwall Reports asked health and council bosses to explain how their original ACO became an ACS. The FOI answer says: “The change in terminology reflects changes in the common nomenclature to describe emerging policy in this regard nationally. In 2016 the term ACO was being used as an umbrella term for a range of different arrangements.
“In 2017, the application process run by NHSE differentiated between ACSs and ACOs, and earlier this year there has been a further change nationally from Accountable Care Systems to Integrated Care Systems (ICSs).
“The local focus has always been on the development of a locally integrated health and care system. Planning guidance issued by NHSE in March 2017 distinguished between the development of Accountable Care Systems (ACSs) as an ‘evolved’ version of an STP that is working as a locally integrated health system and the establishment of an accountable care organisation (ACO) where the commissioners in that area have a contract with a single organisation for the great majority of health and care services and for population health in the area.
“In line with our integration aims locally, the local system developed an expression of interest in becoming a first wave ACS. This was discussed at a workshop of approximately 40 senior leaders, including clinicians, on 4th May 2017, prior to the expression of interest being submitted, with the Council being one of the signatories.”
Above: Cornwall’s original proposal. Below: spot the difference