These slides were used as part of a talk for Sheffield Health Watch on the idea emerging from NHS England that the future direction of NHS reform will be the creation of Accountable Care Organisations (ACOs)

1. Accountable
Care Organisations:
What are they and should we
be worried by them?
Dr Simon Duffy from the
Centre for Welfare Reform, Sheffield
They’re reforming the NHS (again)

2. • NHS England has recently outlined ambitions for Sustainability
and Transformation Partnerships (STPs) to evolve into
‘accountable care systems’ (ACSs) (after ‘several years’)
• Accountable Care Organisations (ACOs) build on previous
efforts [Health & Social Care Integration, New Models of Care?]
to integrate services in the NHS and draws on experience from
health systems in the USA and other countries.
• The language of accountable care comes from the USA, where
ACOs [also called Health Maintenance Organisations (HMO)] are
the latest manifestation of well-known integrated systems, such
as Kaiser Permanente, which have a much longer pedigree [in
fact its as old as the NHS]. They come in a variety of forms from
integrated systems to looser alliances and networks.
Original text from The King’s Fund [parenthetical comments - me]

3. • First, they involve a provider or, more usually, an alliance of providers that
collaborate to meet the needs of a defined population. Second, these providers
take responsibility for a budget allocated by a commissioner or alliance of
commissioners to deliver a range of services to that population. And third, ACOs
work under a contract that specifies the outcomes and other objectives they
are required to achieve within the given budget, often extending over a number of
years. [i.e. They collapse the concept of the internal market and the purchaser
and provider split which has operated for the past 25 years in the NHS.]
• The most ambitious plans for ACOs in England extend well beyond health and
social care services to encompass public health and other services. In Greater
Manchester, for example, the aim is to use all public resources to improve health
care while also tackling the wider determinants of health. This work, and that of
other Sustainability & Transformation Partnerships (STPs), points to the
emergence of what we have called population health systems, which seek to
integrate care and to improve the broader health and wellbeing of the local
population. [i.e. They might align with the emerging and confused world of
devolution with its uncertain boundaries, powers and systems.]
Original text from The King’s Fund [parenthetical comments - me]

4. This may sound new, but this kind of idea has been kicking around
for decades, often with reference to the US organisation Kaiser
Permanente…
• NOT Keyser Söze, but a non-profit corporation with 10 million
members in 6 states, i.e. about 3% of US population often called
a Health Maintenance Organisation (HMO).
• It is effectively a ‘privatised’ version of what the NHS already is -
a systemic effort to improve health of a whole population -
working with a fixed level of funding.
• The internal systems have evolved over a very long time.
• The HMO (which includes health providers) can reward its
component members from the savings it makes.

5. https://www.kingsfund.org.uk/publications/population-health-systems/
kaiser-permanente-united-states
“Kaiser Permanente’s structure and its longstanding efforts to
integrate services are well known and described in detail
elsewhere. Key organisational features include its role as both
insurer and provider of care (within and outside of hospitals),
and the use of capitated budgets for members’ care across
regions. Among other things, integration of care at Kaiser
Permanente is supported by population risk stratification, an
emphasis on prevention and self-management, disease
management and the use of care pathways for common
conditions, case management for patients with complex
needs, extensive use of technology and population data, and
a model of multi-specialty medical practice where unplanned
hospital admissions are seen as a ‘system failure’.”

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC64512/
“The widely held beliefs that the NHS is efficient and
that poor performance in certain areas is largely
explained by underinvestment are not supported by this
analysis. Kaiser achieved better performance at roughly
the same cost as the NHS because of integration
throughout the system, efficient management of
hospital use, the benefits of competition, and greater
investment in information technology.”

7. the obvious question is
If HMOs are so great why
is US health care so poor?
BUT…

8. Melissa Hellmann, Time Magazine, 2014
“The U.S. health care system has been subject to heated
debate over the past decade, but one thing that has remained
consistent is the level of performance, which has been ranked
as the worst among industrialised nations for the fifth time,
according to the 2014 Commonwealth Fund survey 2014. The
U.K. ranked best with Switzerland following a close second.”

9. Judge a tree by its fruit,
but perhaps don’t
cherry-pick the best fruit

10. Most HMOs
are not as
good as Keiser
and many are
associated
with severe
rationing or
promoting
institutional
solutions

11. Changing organisational structure
does NOT necessarily mean you’ll
get the outcomes you want.
Especially when the people, culture
and leadership are all the same.

12. If we pay attention to the
details of what the best HMOs
do then what do we learn?
https://www.kingsfund.org.uk/audio-video/stephen-
rosenthal-developing-accountable-care-organisation

13. HMOs try to pay attention to upstream
causes of ill health…

14. Stephen Rosenthal, Senior Vice President, Population Health Management,
Montefiore Health Systems
“So we looked at the social determinants of health and
we found that in all instances they raised the cost of
care. And so focusing on them gives us an opportunity
to lower the cost of care.”
…but they do this without the legal
and moral authority of the NHS.

15. HMOs try to organise levels of care in order
to prevent crisis and extra costs…

16. Stephen Rosenthal, Senior Vice President, Population Health Management,
Montefiore Health Systems
“But we don’t have the benefit of a National Health programme,
but because we’re disproportionally government programmes,
it’s almost as though our community of providers and system is
disproportionately a government programme or a single payer”
…but so does the NHS and with more
control, coherence and legal clout.

17. HMOs try to provide some governance
structure to drive change…

18. Stephen Rosenthal, Senior Vice President, Population Health Management,
Montefiore Health Systems
“So our governance structure, I will just talk a moment about that, begins with the
Monterfiore IPA structure. And that governance is in equal balance between the providers in
the community, the employed providers, as well as the institutions, and that’s the entity that
bears the financial risk in all of our models. And as you can see we have over 4,000
providers that are in that community touching some 400,000 plus individuals. And then the
ability to manage those relationships between the payers, the governments, the providers,
and the patient relationships, the community activities, we created the care management
organisation or company, which is what I run, that essentially in many ways operates similar
to an insurance company, has all of the infrastructure around that, but it’s goal is to really
manage the relationship of the patient and the various providers that are in those
communities that these patients live in. And develop the kinds of programmes that will
actually ultimately improve their overall care.”
…but this the NHS is already meant to be
accountable both centrally and locally.

19. Is there anything an HMO does
that the NHS can’t do?
• It does help stop doctors from doing private work on the side
• Over a long-term it’s possible that better HMOs might win out over worse (but
that’s a very optimistic hope).
• They may be better at encouraging helpful competition between different kinds of
providers, but US healthcare remains very defensive and over-medication and
medicalisation are rife.
• You may provide better personal incentives for the leaders, doctors and ‘owners’
to promote strategic cost management and innovation (if you’re extremely lucky).
• But remember that HMOs also have incentives to lobby and corrupt the powerful
in order to gain advantages that have nothing to do with the public good.

20. “Accountable Care Organisations” seem like
another example of a Government promoting a
critical weakness as if it were a virtue?
(cf. introduction of Personal Independence
Payments as way to justify cuts in Disability Living
Allowance - you name the programme by the very
thing you’re destroying.)

21. Best HMOs NHS
US health system is crazy drunk,
but the best HMOs act like a
sober designated driver
UK health system is sober but
we give control to political
leaders who are drunk on power

22. The main problem in the NHS is a failure of
self-discipline at the leadership level… they
can’t stop reforming it until it’s broke.

24. Health authorities (involving local authorities) used to be
responsible for improving the health of their local population
and they funded providers, hospitals etc. from within a fixed
funding base
• ‘Reforms’ from 1992 onwards distinguished the role of
‘purchaser’ from ‘provider’ in the hope that purchasers
could take a less self-interested perspective and drive
positive change. [This is clearly seen to have failed.]
• Since the 1960s there has been constant talk of health
and social care integration and attending to the social
determinants of health. [No good model has yet emerged.]
• Tony Blair’s government introduced centralised tariffs to
pay for additional services and reduce waiting times.
[That system is now collapsing as the money runs out.]

25. To some extent we are just back where we began:
• But we have abandoned the assumption that one particular nationally defined
structure will solve the problem of how to create the best outcomes within the
available budget.
• It is good that providers are now seen as part of the solution.
• But we are likely to further weaken democratic accountability and the principles
of good leadership.
• It seems like a fudge in the light of austerity and our ongoing constitutional crisis.
• Some places may see some better long-term thinking, experimentation and the
social change that is at the heart of positive change.
• But short-term pressures and crisis will probably lead to a period of fire-fighting
where cuts and changes are hidden by the smoke of organisational change -
promising much, delivering little.
• In the worst case scenario ACOs are simply packages of services that could be
privatised on the back of trade deal with Trump’s America.

26. Are we really just
ducking more
fundamental
questions?

27. • Inequality is primarily created by Government policy,
especially tax-benefit policy
• Local engagement and community development relies on
giving power and control to local democratic bodies
(local government anyone?)
• The quality of environment, pollution and housing is a
function of national policy and local leadership
• Mental health is shaped by prejudice, inequality,
exclusion and a range of social factors
• Weaknesses in NHS performance may be connected to
perversity of allowing private practice as a side-business

29. From Duffy (2017) Heading Upstream

30. From Duffy (2017) Heading Upstream
Positive change begins by attending to
citizens, families & communities

31. Who is accountable
for what?
What actual changes
lie behind the
structural?
What constitutional
changes should we
be seeking?
3 Big
Questions

32. if anyone’s interested in more meaningful
changes in healthcare check out these

33. www.cforwr.org
@citizen_network
@CforWR
@simonjduffy
fb.me/centreforwelfarereform
fb.me/citizennetwork
e simon@centreforwelfarereform.org
www.citizen-network.org