NHS reforms

Mackey denies legal constraints as accountable care systems confirmed

NHS England boss Simon Stevens has confirmed the nine areas that will officially form part of the first wave of accountable care systems (ACSs) in the country, covering a total of seven million people and backed by a funding boost of £450m.

Speaking during the second day of NHS Confed17 last week, Stevens revealed that Frimley Health, South Yorkshire & Bassetlaw, Nottinghamshire, Blackpool & Fylde Coast, Dorset, Luton (with Milton Keynes and Bedfordshire), West Berkshire, Buckinghamshire and Devo Surrey have all been confirmed as England’s first ACSs.

This differs only slightly from the names of likely candidates published by NHS England earlier this year, with Northumberland and Greater Manchester no longer featuring in the list – although the latter has individually indicated that it is on track to develop local care organisations (LCOs).

“We are committed to local leadership, and as Jim Mackey [CEO of NHS Improvement] said yesterday it’s not simply a return to each organisation or institution doing its own thing, but local leadership as systems with accountability for population improvement without all of the fragmentation in governance,” Stevens told delegates.

He also took the opportunity to promise the audience – comprised largely of leaders and executives in the health and care sector – that care redesign definitely works, with some vanguards already showing early signs of substantial efficiencies and service improvements as a result of reform.

Some are cutting the rate of emergency hospitalisation by two-thirds, for example, while others have also seen a two-thirds drop in the referral rate as a result of redesigning the interface between general practice and outpatient departments.

“In places like Ipswich, as a result of the combined work of the hospital and GPs, they cut referral rates in absolute terms by 11% over the course of the last year,” the NHS England CEO explained.

“Down in Frimley, their creation of practice hubs for half of their area has reduced referral by 7% compared to the other part of their area where they haven’t yet done that and are up by 10%. The fact is that this recipe works – we just bloody well have to get on with it.

“I don’t think, as we take stock of where we’ve got to, that we should have anything other than pride in the work of the NHS over the last year. I don’t think we should have anything other than quiet confidence that we know what we’re doing in the year ahead. But having said all that, I also know we should acknowledge just how difficult it is and is going to be.

“But yes, we have a plan, we know what we’re doing. It’s complex and challenging, but frankly, let’s stay focused, let’s stay practical, let’s stay positive, and let’s get on with it.”

Working within the law

During the first day of Confed17, Mackey also revealed that it is possible to get “90% of the way there” with ACSs and accountable care organisations (ACOs) within the current legislative framework – “but we need to prove it”.

“We need to find some ways in this next phase of doing all of that,” he said. “When people say ‘I’d love to do that, but…’, often the ‘but’ is imagined – it isn’t actually a real legal constraint. It is actually a behavioural constraint.”

This will undoubtedly come as welcome news to the health and care system, especially after health secretary Jeremy Hunt suggested that legislation specifically designed around sustainability and transformation plans (STPs) is likely to be pushed until after Brexit negotiations are concluded. And even then, it is questionable whether the government will be able to legislate without cross-party support for its reform programme.

“It would be really nice if we could say, ‘there is a legally agreed model here that says there is a new hybrid, which is also an ACO, and it is legally signed off and stamped’. If we are honest, I still think we are feeling our way into that,” added Mackey.

“I would really like to see a nice chart that said over two years, we are going to move everybody from there to there, i.e. ACOs, and through that period we’ll adjust our regulatory system and arm’s length bodies and the interaction with those entities, and simplify it for people to make decisions locally.

“But we are not in a place where we have actually agreed that this is the destination, first of all. We need to go through a process, quite quickly, of agreeing that.

“I think this year we will find ways of showing that it is possible within the law. Generally, I see appetite from all sides to get to that point. There are understandable issues in specific economies or in the practicalities of how it’s done. But we need to work through the detail so people can actually see that it’s better on the other side.”