WEST CORNWALL HEALTHWATCH : RESPONSE TO THE CORNWALL

“ACCORD” ACS FOR HEALTH AND SOCIAL CARE     28 January 2018

Introduction

West Cornwall Healthwatch believes that the concept of integration of health and social care is a laudable aspiration which could yield important results if implemented with sufficient funding and time, through locally-based bottom-up initiatives.

However, WCHW notes that recent reports by the National Audit Office (see notes 1, 2 below) have stated that:

-    financial problems in the NHS are endemic and this situation is not sustainable

-    there are substantial barriers to integrated care, particularly relating to the legally distinct systems of health and social care, and the complex range of organisations, professionals and services involved

-    there is no evidence base to support the proposition that integration saves money, reduces hospital activity or improves patient outcomes

We also note that Cornwall Council is under severe financial pressure and unable to maintain its budget for adult social care.

In this difficult context, the proposal for an Integrated Strategic Commissioning body, which cannot replace existing organisations areas of responsibility and lines of accountability, is likely only to add another tier of bureaucracy and to embed the historic under-funding of services. The ultimate control over the funding available for the integrated services will remain, via various and complex routes, with

Central Government.

There is evidence that, given adequate support, local solutions built from the ground up can benefit certain groups of patients. WCHW is strongly in favour of locally developed, “bottom-up”, “placebased”  initiatives to integrate services, that can produce better outcomes for local residents.

Issues

WCHW has a number of concerns about the current process and proposals contained in the “Accord” document and as presented to the Inquiry Panel established by the Council’s Health and Social Care Overview and Scrutiny Committee:

STP/Shaping Our Future - so much detail of the health and social care provision for Cornwall, we are told,  which will be defined by the STP/SOF, and is not yet fixed. The nature of its proposals is bound to have an impact on the specifics of the Integrated Strategic Commissioning structures and processes, on the nature of the contract(s) between an ISC and Accountable Care Partnership, and the formation and practice of the ACP. We would argue that logically, these organisations and this process should only be prepared after the STP/SOF is completed.

(As Jackie Pendleton, chief operating officer of NHS Kernow Clinical Commissioning Group, said at the Health and Wellbeing Board only last week, in relation to MIUs,  “it has to be the service model which leads, and then the organisational structures which support that. It can’t be the other way round.”)

Regulatory Framework - Under current NHS and Social Care regulatory and standards frameworks, new organisations will have no statutory powers without changes to legislation. We believe it is not appropriate for Cornwall Council or the other “Accord” bodies to proceed until the regulatory environment is fully understood.

Levels of Management - there is a clear danger that, if existing NHS structures continue (and until any changes are made through legislation), the ISC will insert another level of management, bureaucracy and cost into the system. Tensions and conflicting interests, relating to different Government funding streams and statutory responsibilities, severely limit the ability of partner organisations to work in an integrated way, and an ACS risks simply duplicating management and administration. This issue needs to be explicitly addressed in the proposals for the ISC.

Funding - funding is a critical issue. As noted above, there is an acknowledged legacy of under-funding across the NHS, and as the recent National Audit Office report (2, below) says “Partnerships need to find effective ways of managing demand for services or delivering services at lower cost or both. Without these, the NHS will have to make difficult choices about which services it can or cannot afford.”  Cornwall has been historically under-funded (by comparison to other areas, local need, and the particular circumstances of a “remote” rural county). Choices already made in Cornwall have had a damaging impact on services to patients, and it seems certain that further cuts are to come.

Although it has been suggested that £100m of “debt” will be written off, there is an immediate need for significant levels of additional funding to stabilise the current situation and invest in new facilities, staff and other resources. Also there is a need for financial support for development, engagement and training for the new processes - and not least in IT systems (see below).

In the longer term, when budgets will continue to be determined by Government, the Council and partners should not have taken on the responsibilities of an ISC unless it has clear guarantees about the levels of immediate and future levels of funding.

IT - an integrated care system can only operate properly when a fully functioning IT system is in place. This has failed to materialise, despite numerous attempts and changes over the last 17 years, for health alone. A new system would be required not just for patient records and management of clinical pathways, or for management and accounting purposes, but also to support proper strategic management, monitoring of outcomes and proper contract management between ISC and Accountable Care Partners. Cornwall Council, as potential lead in the ISC, should not take on that role until there is a clear programme to fund and implement such an IT system in Cornwall.

New Models of Care - alongside the moves towards ACS across the country, some areas have seen the introduction of new care models to better meet the changing needs of their population by integrating care and improving health. Two models are PACS (Primary and Acute Care Systems, hospitals often taking the lead in joining up acute services with GP, community, mental health and social care services) and MCPs (Multispeciality Community Providers, with GPS working “at scale” to forge closer links with community, mental health and social care services). WCHW believes that developing integration at this level, through whatever appropriate and viable models, delivers better local services and outcomes, rather than focussing on the ISC level. Taking energy and resources to work on the ACS, in the absence of experience with new models of integration will only delay the implementation of local, patient-focussed initiatives.  

Not only should Cornwall Council and its partners be encouraging these new models of health and social care, but should also focus its immediate attention on the distribution of health and social care facilities across the County.

ACS Process and Pilots - the Accountable Care approach was promoted by the Department of Health and NHS England on the basis that it would first be piloted in selected areas, to test and demonstrate the potential to integrate services, and test governance, financial , regulatory and contract issues. Lessons are being learned already, including the importance of building on quality STPs and on local experience in service integration, but this “pilot” process is still in its early stages, with more time required to identify the key factors for success nationally and in Cornwall. WCHW believes that is essential that Cornwall waits until more is understood from other areas before attempting to design its own ASC.

The future of ACS - we are know that Sarah Woolaston, MP, Chair of the House of Commons Health Committee wrote to the Secretary of State for Health & Social Care requesting a delay in the introduction of the proposed new contract for Accountable Care Organisations, and time for the Committee to hear evidence around Accountable Care models and report after Easter - and that he has responded by delaying part of the process. In the light of this and other processes (e.g.Judicial Review), which may affect the timing and future shape of Accountable Care Systems we believe it would be wise to delay implementation in Cornwall.

Conclusions

WCHW has serious concerns about the pace of the moves to set up an Integrated Strategic

Commissioning body in Cornwall, believing that it would be appropriate to take more time to:

1.    Meaningfully consult with all key stakeholders, particularly the public of Cornwall and the Isles of Scilly, and the health and social care workforces.

2.    Clarify how the STP/SOF, the Five Year Forward View and the ACS will fit together and define the organisational structures and measures appropriate to the STP/SOF.

3.    Wait for evidence and outcomes from the current pilots elsewhere in the country.

4.    Wait for guarantees regarding immediate and longer term funding, including funding to implement the ACS itself.

5.    Await further developments in the financial, regulatory and legislative or guidance systems for ACS.

Our immediate fear is that Cornwall Councillors, acting without sufficient information or time to reflect, will agree to impose a system which is not fit for the specific circumstances and priorities  of Cornwall, and is not financially sustainable, and will thus destroy the trust and support of residents.

References from National Audit Office reports

1.   Department of Health, Department of Communities and Local Government “Health and Social Care Integration”, Feb 2017

2.   Department of Health and Social Care, “Sustainability and Transformation in the NHS”, Jan 2018

JF, 28/1/18