What NHS England isn’t telling you, and more indispensable insight for commissioners. By Dave West.

We are seeing, chivvied on by the Commons health committee integration inquiry, the completion of a policy shift away from promoting hard “accountable care organisations” – aka new and very different forms of health and care providers, contracted in a specific way – over to “system working”.

This started with the development of Sustainability and Transformation Partnerships during 2016 and has taken hold as it became even clearer ACOs are a) really difficult and quite risky, and b) controversial/unpopular.

Now the plan appears to be for ACOs to soak up all the political toxicity (they are the focus of campaigners’ legal challenges and do involve procurement), emphasise they are a niche interest, and if necessary throw them on the policy pyre altogether.

Meanwhile, after a brief hiatus, it is said to be “full speed ahead” for integrated care systems.

The ICS club is intentionally inclusive with few definitive requirements, the principle being for existing organisations to genuinely work together and – in a non-specified way – promote preventative and out-of-hospital services. 

What might these latest policy twists mean in coming months? A few observations:

1. Legal constraints are still a big problem. Ironically, ACOs are the focus of current judicial reviews, but it is in the very grey area of “system working” that the legal framework is more strained. NHS organisations with boards, governors, GP members and accountable officers are called on to make decisions beyond their immediate interests and responsibilities. Informal deals are encouraged and there are incentives to limit patient choice. System leaders are asked to act as if they have levers or responsibility which they do not. It relies even more than usual on very influential individuals – “backing energy and leadership where we find it”, as Simon Stevens has put it.

2. Acute trusts as the main incumbent will nearly always be back in the driving seat. ACOs were meant to play the “grit in the oyster” role. They were a new way to try to put primary and community care in the driving seat, as illustrated by Dudley and Manchester – the only two areas anywhere near creating a hard ACO. The idea was to put substantial capitation budgets in their hands. These were never going to pop up all over England but just a smattering would disrupt the current order. For general practice, the plan now is working towards more rudimentary groups and networks – something Mr Stevens signalled back in December 2016.

3. We’ll still have soft ACOs. They will be known as integrated care organisations or integrated care partnerships. The idea of contracting acute care, community services, social care and even general practice all in one go wasn’t invented in 2014. Acute trusts are the largest providers of community healthcare – several senior NHS officials would instinctively spread that further. Northumbria and Salford foundation trusts are among those already running social care, and Wolverhampton and Yeovil hospitals are examples of those taking on GP provision. More common are alliance/partnership agreements which seek to create financial ties between trusts and GP practices as incentives for prevention. One result of turning down the volume on ACOs is to refocus attention onto making softer arrangements work.

4. Risk stays with the NHS and is shared across the (NHS) system. Andy Williams, STP lead in the Black Country patch – home to several new care models – pointed out in a webinar we held this week that ACOs implied passing financial risk to the provider. In system working, risk must be embraced by the area’s NHS organisations and spread across them. Andy pointed out a big problem here is that for local councils – which need to be involved in the integration – it’s anathema to lend financial support to neighbours in the same way because of democratic accountability, and financial governance which emphasises each council’s duty to break even.

5. Pragmatism and “enablers” are in. At the back of STPs were often-ignored sections on enablers – themes like attracting and retaining workforce, sharing staff, trying to get IT working, and sharing some basic functions. With actual STP service plans going nowhere fast, some are following the spirit of system working and using STP apparatus to work together on these functional and pragmatic matters.

6. We are stuck in an interim ”firebreak” financial regime. ACOs weren’t going to fix this overnight but were one route to create agreed payment methods that promote, instead of work against, preventative and joined up care. That work has been on the national NHS to do list for years. The planning guidance confirms another year of even bigger centrally held, arbitrarily allocated, sustainability funds (the “transformation” pretence dropped), which were meant to be a one-off firebreak. They are generally not particularly encouraging of system working.