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

Bite your hand off

The NHS’s settlement in this month’s budget could involve turning up the heat under accountable care systems, in return for whatever new capital and revenue funding the Treasury can cobble together.

Such a deal, currently a part of pre-budget negotiations, would represent further government backing for the ACS approach. It suggests the Treasury still buys into “accountable care” as a way to bend the healthcare cost curve.

So far the first eight ACS areas (plus two “devolution” areas), while under pressure to deliver, have been given space to design how they want to work in future. They are going about things in different ways.

They are receiving lots of support, senior attention and assurance that the rules will be broken to help them, and a bit of extra money. Those involved can be pleased with that, and it could be the best available recipe for finding a way through the NHS’s current predicament.

But the danger of selling reforms to politicians is they might bite your hand off.

A deal with the Treasury could provide permission to create genuine system control totals (not yet a reality, as far as I can see), depart further from payment by results and delegate regulation to ACSs. This is great news for areas ready to take these changes on, but the flip side will be pressure on ACSs to do this speedily even when some are not ready.

Another likely requirement would be big leaps in accountability: slashing the number of people in charge, sweeping away commissioners with the promise of big transaction cost savings.

Again, these are things not all ACSs will be able to deliver, particularly as they remain straightjacketed by law – an irony hopefully not lost on those negotiating with this legislatively hamstrung government.

For example, while the Frimley ACS is perhaps fairly cohesive and coming together under a strong leader; up in South Yorkshire, where there are nearly a dozen trusts, five separate CCGs and six councils, and where STP spells “Sheffield takeover plan”, a decisive shift would probably scare the horses.

A deal with government might require more ACSs to spring up too, regardless of whether there are enough mature systems with a chance of delivering. NHS accountable care won’t curb demand and cost growth overnight, and artificially high hopes often precede disappointment and recrimination (see: the vanguards and others).

Foundation trusts for the future

One big prize from a new deal with the Treasury could be – you would hope – some release from the strict rules it imposed when putting the NHS on the financial naughty step in 2015, particularly the sustainability and transformation fund.

It will be a gradual if not glacial process, but ACSs will be first to begin shifting the STF from lump sums propping up bottom lines into something more constructive.

This puts a sharp point on some very important questions: what financial regime will replace the crisis mode combination of STF, control totals and system risk funds? What type of organisations does the NHS want for the future – and, therefore, should receive the lion’s share of the STF billions?

Jim Mackey wrote in the summer: “I think we all agree [there] can’t be a simple return to foundation trust freedoms, because our views of how a health system could function have evolved since this era, but instead must recognise institutional needs and system needs.”

In the short term, there’s a case for the STF to be put behind ACSs and some STPs – something the Treasury, with an apparent trust in accountable care, would presumably support.

But in longer term, the NHS probably needs its existing providers, the largest group being foundation trusts, to adapt faster to the integrated and preventive model, serving a population, which it wants for the future.