In 2014 NHS England published The Five Year Forward View. Through it NHSE outlined objectives for the NHS that were then, and have proved to be now, totally unachievable. The clear motivation was a cover story for how the NHS was to survive an government-imposed unprecedented funding crisis – £22bn of underfunding from the Government for the NHS from 2015/16 to 2019/20. Evidence-based need was for £30bn increase in annual funding over those five years – the Chancellor and Prime Minister refused to agree more than £8bn – and that was conditional on demands being met for major NHS disruptive reconfiguration.
The strategy to implement the Five Year Forward View was through Sustainability and Transformation Plans. The vehicles for these plans morphed into Accountable Care Systems and Accountable Care Organisations – language that comes from the USA. Toxified by campaigners, they are now in their fourth iteration repackaged as Integrated Care Systems to be delivered by Integrated Care Providers, appointed through tendering and open to private organisations – contracts worth billions per year each one to run an individual fragment of a dispersed NHS for extended periods of 10-15 years, covering the health and care needs of up to a population of 500,000. This final phase is the spectre facing the NHS, currently out to consultation till 26 October 2018. See much more information and analysis at Health Campaigns Together and our video on ICPs and our post on the NHSE consultation.
Through the following section we’ll give an overview of each of the stages of these systems over the last 8 years. You can click below to skip to a particular section of interest.
Sustainability and Transformation Plans (STPs)
STPs are 5-year plans that divide up England into 44 ‘footprint’ areas and call for a massive change to the NHS in each area. Despite claims that they are there to ensure regional health services better cater to local populations’ needs, they are in fact a way of cutting services to meet ever-dwindling budgets and allow easier privatisation of what is left.
The plans were developed in secret, with no public consultation. They include widespread cuts to acute services (hospitals), with people having to travel further and further to get the treatment they need. This is hidden by using obtuse, ‘managementese’ language (eg, ‘the wellness paradigm’). They mention ‘community care’ as alternatives when in fact the community does not have the capacity, funding or in some cases expertise to pick up the demand. Further cuts are being planned which go beyond the STPs in some areas even before they have been implemented, because the under-funding is so serious. STPs will also make it even easier to ‘contract out’ services to private suppliers, further undermining the NHS in that area.
Keep Our NHS Public is opposed to STPs. They are a way of breaking apart the NHS, not the regional improvement in integrated care they are proclaimed as.
You can find the details of the STP for your area on the Health Campaigns Together web site.
STP now stands for ‘Sustainability & Transformation Partnership’
In March 2017, Simon Stevens published his implementation plan for STPs to deliver changes equivalent to £22bn of cuts, Next Steps on the NHS Five Year Forward View. He introduced his assumed organisational form that the new sustainability and transformation partnerships would take – a coalescence of provider trusts and CCGs with any willing local authorities in area-based alliance organisations.
Stevens named these ‘Accountable Care Systems’ (ACS). He predicted that these would evolve in a variable number of years but in all areas, into hardwired structures he had unashamedly given the USA-derived title of ‘Accountable Care Organisations’ (ACOs). The ‘ownership’ of ACOs would be via a 10-15 year contract tendered out to an interested party or parties, explicitly including the private health and financial industry. Model contracts put forward the possibility of a Special Purpose Vehicle. SPVs are notorious in the case of financial wheeler-dealering of private finance initiative contracts (PFIs). See our review of ACSs and ACOs and the very helpful full briefing.
In new NHSE guidance issued 2 February 2018, Stevens renamed ACSs as Integrated Care Systems (ICS) and accountable care organisations as Integrated Care Providers (ICPs)- explicitly to avoid the link with the US cost-capping, insurance-based accountable care organisations.
We have developed resources to help understand what is being planned, and to help in campaigning:
- a summary briefing on integrated care systems and ACOs
- a more detailed briefing on integrated care systems and ACOs
- an introductory letter to contact your MPs and
- an introductory letter to contact your councillors
All available in our Resource Cabinet under ‘Accountable (Integrated) Care Organisations and Systems’.
As little as six years since the massive restructuring imposed by the Health and Social Care Act 2012 (HSC Act), the National Health Service is again undergoing radical change, this time at breakneck speed and without parliamentary consent.
Whereas the HSC Act increased competition, recent changes introduced by NHS England (NHSE) appear to do the opposite, but these appearances are misleading.
Accountable Care Organisations: they are not accountable, they don’t care and they are not very well organised
John Lister, Editor – Health Campaigns Together
Far from replacing competition with collaboration, NHSE intends to replace multiple smaller NHS contracts with a single long-term lead Integrated Care Provider contract (ICP and previously known as ACO) contract for each area of England of up to 500,000 population. These ICPs would continue to issue multiple smaller subcontracts!
NHSE argues that introducing ‘integrated care’ (the term which has replaced the more politically toxic ‘accountable care’) is central to Government aims for ‘financial sustainability’ of the NHS. In this context, ‘sustainability’ means reducing services to match insufficient funding: despite being one of the richest countries in the EU, the UK currently spends below EU average levels on healthcare. 
Integrated (previously ‘accountable’) care systems: what is wrong
- Accountable Care Systems (ACS) have been re-packaged as Integrated Care Systems (ICS)
- ICSs involve partnerships between providers and commissioners and occasionally with local authorities (confusingly call Integrated Care Partnerships (ICPs)
- Accountable Care Organisations (ACOs have been re-packaged as Integrated Care Providers (ICP) – the contract for which is subject to NHSE’s consultation (August to 26 October 2018).
Both ACOs/ICPs and ACSs/ICSs need to be resisted for the following reasons:
- They are being introduced without adequate public involvement or consultation; and where NHS and social care services are seriously underfunded;
- They are being implemented beyond any legal framework, creating problems of governance and accountability;
- They have no robust evidence baseto support their use in the context of the English NHS;
- They will help strip NHS assets, such as land and buildings, so ending the social ownership of much of the NHS estate while allowing private companies to profiteer from it;
- They will apply unprecedented cuts in spending(£22 billion by 2020, compared with 2015 levels) and transfer the NHS’s funding shortfall to new local, self-contained areas.
- They incentivise rationing of servicesand – even more concerning – denial of care and so are fundamentally at odds with social solidarity and the values of equity and universalism that underpin the NHS;
- They increase the potential scope of NHS privatisation. For example, multiple procurements will be replaced by a single, major, long-term contract to provide health and social care services for an entire area. The draft model contract for ACOs published by NHSE allows for, and is likely to attract, bids from multinational corporations. 
- They rely on unrealistic expectations, for example about collaboration and risk-sharing between private and NHS providers.
- They entail ‘transforming’ the NHS workforce, replacing experienced clinicians – including doctors and nurses – with technologies, and introducing new lower skilled and lower paid roles, such as ‘physician and nurse associates’. ACOs are likely to under-deliver required skill levels and undermine NHS terms and conditions of employment.
This is a time of unprecedented NHS and social care funding shortfall. No one can deny that acute, primary care and community NHS services and social care need to be better integrated. But major funding input is the first and foremost requirement, to restore safe level of service provision and to facilitate moves towards better integrated delivery of services.
What is clear is that despite the lack of evidence, accountable care systems are being introduced at breakneck speed, and in the absence of public involvement and consultation, parliamentary scrutiny or appropriate legislation.
Simon Stevens has made clear his intention that ACSs will develop into ACOs and NHS England’s model contracts assume a tendering process inclusive of bids from private companies or special purpose vehicles to run whole systems of the erstwhile NHS. Here and now, the development and management of accountable care systems themselves are being offered to private companies – as in Greater Nottingham.
These unevidenced and undemocratic proposals are facilitating increasing privatisation of the NHS, by giving private corporations new roles and powers to shape the NHS in their interests.
We say: these new models of care should be opposed.
What is needed
Integrated care does not require commercial contracts and the involvement of corporates. For the success of a truly integrated system of health and social care, key steps are needed:
- Increased funding of the NHS and personal social care (e.g. to average EU levels) to ensure that integration can deliver improved patient services rather than be the disguise for ‘efficiency savings’ and cuts;
- Personal social care provided on the same terms as health, free at the point of use and paid for from public funding as in Scotland – unlike means-tested charges for social care alongside free health care which will prevent integrated care;
- Full public involvement and consultation;
- Robust piloting of future plans for integration and in-depth, independent evaluation;
- New legislation that protects Bevan’s founding principles of the NHS; ends the marketisation and fragmentation of the NHS; and re-establishes public bodies and NHS services that are accountable to Parliament and local communities – legislation such as that drafted in the NHS Bill 2016-17.
- In addition to this summary, see our full KONP briefing here and other resources
- HCT’s resource: Integrated Care Monitor and KONP on the ICP contract
 There have not been actual cuts in total NHS funding since 2010 – funding has risen very slightly in cash terms. However, the rise has been far slower than the growth of population need and cost pressures. £22bn is the gap between the virtually frozen funding 2015-2020 and the steadily rising costs and pressures, and that implies “savings” which must amount to cuts.