Dr Brian Fisher: Don't believe the hype - ACOs could endanger the NHS

Accountable care organisations (ACOs) springing up across England could put the NHS at risk, writes London GP and Socialist Health Association honorary vice president Dr Brian Fisher.

Dr Brian Fisher (Photo: Dan Wootton)
Dr Brian Fisher (Photo: Dan Wootton)

ACOs are a phenomenon we shall be seeing more of in the NHS over the next few years.

The £6bn, 10-year contract for a single provider to run all out-of-hospital health and care services for Manchester's 600,000-strong population is the latest variant of an ACO - it calls itself a 'locality care organisation' - and also happens to be the biggest ever NHS tendering process.

The King's Fund think tank describes ACOs as a group of providers contracted by a commissioner taking 'responsibility for the cost and quality of care for a defined population within an agreed budget'.

Care quality

ACO providers are held accountable for achieving agreed quality outcomes within a given budget. They often focus on high-cost patients such as the frail elderly.

There is little data to demonstrate whether ACOs lead to improved care, although a 2015 survey by the Commonwealth Fund and the Kaiser Family Foundation found that doctors’ views 'tilt negative on the effect ACOs have had on the quality of care, and many are still not sure of their effect'.

By contrast, the literature abounds with analysis of their cost effectiveness. And the evidence is mixed. An initial group of US ACOs, which seem to have started in 2010, have improved care at reduced costs according to an analysis published by the Nuffield Trust.

But it looks like that may be because they were very expensive in the first place, so it was relatively easy for them to reduce costs. The analysis also shows that overall half of ACOs seem to have done well, half have not.

As for the accountability of ACOs, they seem to be accountable to their commissioners - but I have seen no mention of ACOs being accountable to their users. That element seems absent from all analysis and description.

NHS integration

Meanwhile, definitions of integration vary – co-ordination between sectors such as social care and the NHS; co-ordination between parts of the NHS, like primary and secondary care; improved links within a discipline like mental and physical health; linked record systems. And often, its meaning slides into increased care in the community.

It seems intuitively correct that better care means co-ordinated care. But there are many claims for integration that are not borne out by evidence. In particular, that it saves money and improves outcomes. Sadly, many STP plans seem to rely on this more or less evidence-free planning.

Large tenders have proven unstable in some cases. The £1bn franchising of Hinchingbrooke Health Care NHS Trust is among those that have ended in high profile collapse.

One positive aspect of ACOs is that they eliminate Payment by Results, the tariff mechanism that underpins the pseudo-market in the NHS, pitting one trust against another and sidelining general practice. In ACOs savings can be recycled and success depends on collaboration between sectors.

However, ACOs (and STPs) are likely to make CCGs redundant, despite their legal status - more sidelining of general practice.

NHS privatisation

ACOs also could open the door for privatisation. Large groups are more appealing than lots of small organisations. Commissioners will have, in NHS England's words, 'a contract with a single organisation for the great majority of health and care services and for population health in the area'. Labour - according to Ellesmere Port and Neston MP Justin Madders, will insist that the ‘single organisation’ be part of the public sector, but the Manchester procurement notice has already attracted the interest of private firms.

So, ACOs don't seem to be accountable to patients and they don’t seem to offer better care. Why should we import an untried and probably ineffective model? I'm not alone in worrying that the government’s not-so-hidden agenda is the destruction of the NHS and its privatisation, and that ACOs are a step in that direction.

The Socialist Health Association rejects the fragmentation and marketisation of the NHS, both the internal and external market. We want to see a co-ordinated health and care service that offers localised care with national standards, spanning the NHS and social care.

Reorganisations rarely improve outcomes. Deckchairs and Titanic springs to mind. What is really needed is an end to austerity – but this government is clearly set against that. Only an adequate financial settlement can deliver the health and social care service that we all want to see.

Don’t be fooled by the rhetoric around ACOs – in the current circumstance, with this government – I believe they are dangerous.

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