Service Reconfiguration

Lack of council voice in accountable care systems leading to NHS scepticism

Only a third of council members have a clear understanding of how an accountable care system (ACS) – NHS England’s chosen model to take forward sustainability and transformation partnerships (STPs) – work, raising a red flag around the potentially dangerous exclusion of local authorities from these vital reform conversations.

In research conducted by Localis, a third of respondents from across local government said they only have a ‘slightly’ or ‘not at all’ clear understanding about ACSs, which the think tank argued “should be a note of concern”.

It also heard criticism that the FYFV update document left the concept of an ACS poorly defined, despite it being a major model shift that “would allow for more strategic commissioning of services based on population-level health and care information”.

“We reached out to a number leading chief executives, directors and cabinet members in local government to ask if they could provide a definition based on their best understanding and we received contradictory answers,” said Localis.

“Some saw it as a ‘single budget for single system’ whereas others stated it was a ‘collective of organisations working to a set of agreed objectives but without the pooling of budgets’. Some were highly sceptical claiming it was the ‘NHS trying to take control of adult service money’.

“There is a weak understanding of precisely what an ACS is and what it is supposed to achieve.”

Overall, concerns have been raised that the future integration between health and social care as part of an ACS has not been “given enough consideration”.

In its interim research note, which forms part of an ongoing project looking into the next steps for health and care integration, Localis said: “When it [ACS] has been discussed it is largely in relation to supporting the hospital system. The precursor to the new sustainability and transformation partnerships, the sustainability and transformation plans, were roundly noted as having minimal involvement from local authorities and in some cases none at all from mental health services.

“Given the purpose of the plans was to enable the intelligent transfer of resources from secondary care to primary care and prevention, and local government is a critical partner to the NHS locally, such a concern about ACSs seems justified.”

In stark contrast to these findings, 70% of councils said they have already been involved in discussions about ACSs, although this has ranged from being consistently active with the STP and CCGs right through to “only at preliminary level”.

“With local health economies moving ahead with this process of reform, the danger is some local authorities get left out of discussions entirely,” said Localis.

One hospital trust CEO interviewed for the research, for example, told the think tank: “I know exactly how the health system needs to looks locally in five or six years’ time, I can’t say the same thing about social care.”

The briefing note makes for depressing reading overall, with an overwhelming majority of respondents suggesting that the new direction for the health and care sphere laid out in the Next Steps document earlier this year had absolutely no impact “on confidence in local efforts to integrate health and social care”.

“We attribute this to the policy officially only recently entering the public domain,” explained Localis. “However, other recent announcements have generated stronger dividing lines amongst local authority leaders and senior executives.”

The end of the purchaser-provider split has also created rifts in local government opinion, with one respondent arguing this move will “make integration far more difficult, as councils are moving in the opposite direction as they increasingly divest themselves of their provider functions”.

“The end of the purchaser-provider split in the NHS seems to be associated with more of a focus on direct NHS provision, rather than on population health outcomes,” added the respondent.

But another interviewee offered a far more positive view, arguing that “having combined leadership for the health services in an area and a finite budget that a partnership is responsible for would lead to less talk and more action/implementation”.

When analysing the emerging themes in health and care integration, Localis concluded there was limited evidence that cost reduction or improved outcomes have been met consistently at scale, in line with similar findings from the National Audit Office.

“With pressure on social care funding reaching a critical level and government soon to be consulting on its future we are forced to ask the question; is health and care integration an inheritance worth preserving?” the think tank considered. “International comparisons suggest the link between integrated care and lower costs is weak.

“Evidence does show that integrated care can highlight previously unmet need and there is anecdotal evidence which suggests patients enjoy a better quality of service if it is streamlined.

“One adult social care director interviewed said that it was entirely possible that integration was achieving outcomes and they were confident it was, just that we were yet to agree a way of accurately measuring them.”

Three emerging themes

So far in its research project, Localis has identified three emerging themes. The first – a consistent message during the entire research – is that integration has become an unhelpful term, loaded with “connotations about structural change and challenges to organisational sovereignty”, which doesn’t “accurately reflect the good local activity that is happening”. A better term, suggested by a council cabinet member for adult’s services, is simply ‘co-ordination’.

The second “strong message” to come from both the NHS and local government during research roundtables was the need to have person-centred care, integrating services via the individual – although this raises questions about data and its accessibility.

“With NHS England altering requirements to share data, which in the words of one roundtable participant ‘will only make it harder to share’ this particular area will be explored further as part of the final research report with a view to making recommendations,” said Localis.

Lastly, there is now concern that after significant investment in the integration process, NHS England “seems to be signalling a loss of patience with the agenda”. But this is not necessarily a bad thing and could potentially open up opportunities to deal with mounting internal problems, as well as allowing council directors to focus on funding prevention and early intervention in the community.