Halfway house reform for the NHS?

28 March 2017

More on the NHS this week, given that Simon Stevens is due to make his  announcement on the future of Sustainability and Transformation Plans (STPs) on Friday. Quite a week: Article 50 on Wednesday; Great Repeat Bill on Thursday; the future of the NHS on Friday. And on Sunday the Government rested.

The head of NHS England is expected to say that seven or eight of the 44 STPs in England are far enough advanced to form accountable care organisations (ACOs) i.e. groups of providers that undertake to improve the health of a whole population. That objective, as against simply achieving a set number of hospital procedures or GP appointments, was one of the core recommendations of Reform’s recent STP paper.

Three questions arise from this.

First and most important, why only seven or eight, or less than a quarter of the NHS in England as measured by STP areas?  Simon Stevens may argue that these areas are the only ones able to push on to ACO status. The natural response to that is that the NHS should have made much faster progress since the publication of the Five Year Forward View two-and-a-half years ago.

More importantly, the danger with a selective, “halfway house” approach to reform is that it creates a group of vulnerable pioneers that are lightning rods for criticism. Most importantly, it leaves 80 per cent of the NHS stuck with an inferior model, in the eyes of its leadership at least.

Second, which organisations will join up under the ACO umbrella? They will better achieve their objective of joined-up care if they include GPs and social care providers. Whether they do so remain to be seen. In his evidence to the Public Accounts Committee in January (extract below), Simon Stevens rightly praised the development of much bigger GP groups able to serve tens of thousands or even hundreds of thousands of people. To my mind at least, the  suggestion was that GPs would stay outside of the ACO model, which would diminish it. (Reform paper on future of general practice here.)

Lastly, to whom will accountable care organisations be accountable? Simon Stevens has already suggested that providers will no longer be held accountable to commissioners, because the purchaser-provider split will disappear in these areas. The fear would be that the ACOs are subject to the national NHS authorities, with all of the bureaucracy and politicisation that comes with that. The Reform STP paper proposed a model of local accountability (for commissioners in that case)

More to come on Friday.

“We have talked previously about the fact that over the course of 10 years, for reasons we understand, a big mistake has been made in the NHS, which is that the rate of growth of hospital specialties has been three times faster than that of GPs—not what anybody would have said was the smart choice a decade ago, but that is what has happened. If you think about the relativities of the 300 million GP appointments versus the 23 million A&E appointments, it is pretty obvious that if you find it harder to go and see your GP, some of that will show up as extra pressure in A&E departments. We have got to do what we said in the GP forward view, which is not just to invest but to make some big changes to the way general practice works, because the old isolated cornershop model of general practice in many places now is not what GPs themselves are saying is required. Bringing together groups of practices so that we can get extra staff services and expanded access is clearly vital not just to what patients experience, but also for the sustainability of the NHS.”

Simon Stevens, evidence to the PAC, 11 January 2017

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