Fast tracked toward an ACO – Is Cornwall’s NHS being ‘Americanized’?

Judicial Review for new system of NHS governance planned for Cornwall

Cornwall’s Health & Social Care system is being fast tracked towards a new system of governance called an Accountable Care Organisation (ACO), a public / private partnership that critics are a calling an Americanization of the NHS.

But as health bosses and council officials in Cornwall prepare for the biggest shake up of service delivery maybe since the NHS began, the whole concept of ACO will now a face legal action to force a judicial review, to ensure full scrutiny of the proposals.

ACOs have the power to award huge contracts for the delivery of health services to the private sector.

According to a report in The Independent senior health professionals and campaigners have instructed solicitors to inform the Health Secretary Jeremy Hunt that they are ‘seeking a judicial review in an attempt to ensure parliament can fully scrutinise the proposals’ They also question the Department of Health’s consultation process calling it “inadequate and unlawful due to the lack of national consultation or parliamentary approval”

Yet if Cornwall’s NHS bosses had their way, we would be further down that lane already.

Cornwall applied to be in the first wave of ACOs in the country back in May of this year but we got turned down.

On 9 May 2017, an expression of interest was submitted to NHS England and NHS Improvement to become a first wave Accountable Care System by the Shaping our Future Programme. Cornwall and the Isles of Scilly were not one of the eight approved across the country (Frimley Health; South Yorkshire and Bassetlaw; Nottinghamshire; Blackpool and Fylde Coast; Dorset; Luton with Milton Keynes and Bedfordshire; West Berkshire and Buckinghamshire)

Officials from Cornwall have been advised informally that Cornwall and the Isles of Scilly will be a ‘fast follower’. A framework for ACS development is being taken forward nationally in conjunction with the first wave ACS sites, which will inform developments locally.

A Department of Health spokesperson told the Independent: “It is completely inaccurate to suggest ACOs are a step towards an insurance based system. They have absolutely nothing to do with the funding model of the NHS, which will remain a taxpayer-funded system free at the point of use, and are simply about making care more joined-up between different health and care organisations”

Health bosses in Cornwall say health and social care provision is crying out for a one stop shop integrated managing body rather than the spaghetti of a system that has developed.

But already some councillors are calling for more private sector involvement right from the start. At the last meeting of the Health and Wellbeing Board it was minuted “that as the plans for models of care and the Accountable Care System developed, wider consultation and engagement was needed to include private health providers.”

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A formal written agreement to integrate health and social care was agreed by the system leaders in 2015.

As part of that process, and the publication of the Cornwall STP, under the title of Shaping our Future, the Chief Executive of the Council together with the Chief Executives of Royal Cornwall Hospital Trust, Cornwall Partnership Foundation Trust and Kernow Clinical Commissioning Group, published a joint statement of intent in letter form.

As well as reinforcing the commitment to transformation through integration, the letter went further in setting out the thinking on the organisational form an integrated system would take:

“Our thinking now is that we will need to move with pace to establish an Accountable Care Organisation (ACO) for Cornwall and the Isles of Scilly and one focal point for the strategic commissioning of health and care. Over the next few months we will explore options for strategic commissioning, determining through the right governance arrangements, the population outcomes for Cornwall and the Isles of Scilly that we wish to achieve in respect of health and wellbeing which then informs the priorities for the ACO”.

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Since the implementation of the Health and Social Care Act 2012, the current overall health and social care system in Cornwall consists in health of a clinical commissioning group for acute and community services (Kernow CCG), NHS England as the commissioner for primary care and specialist health services, two provider trusts serving Cornwall only (Royal Cornwall Hospitals Trust (RCHT) and Cornwall Partnership Foundation Trust (CPFT)), two Devon based acute provider trusts serving North and East Cornwall (Derriford Hospitals Trust and North Devon Hospitals Trust,) 62 GP Practices and a local authority that both provides and commissions social care.

It seems a done deal that the ACO is happening, and fast. They want a shadow structure in place by the spring.

An update on progress establishing the ACO will be heard at the Health and Social Care Overview Scrutiny Committee at the Council tomorrow (29th Nov).

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The council say “The swift development of an Accountable Care System (ACS), comprising an integrated strategic commissioner and a network of providers with a single leadership team are critical to the delivery of the system-wide strategic plans for health and care referred to as the Shaping our Future Programme (S0F).

The health and care system in the UK and in Cornwall faces a range of significant demands, service and financial pressures that no single organisation is able to address on its own – for example taking action to address delayed transfers of care requires clear consistent leadership across at least four organisations (RCHT, CPFT, Adult Social Care and Primary Care) to support improvement and which, despite a plethora of initiatives, remains an area of relatively poor performance”

The development of the ACO, also referred to as the accountable care partnership is the lead responsibility of Kathy Byrne, Chief Executive of RCHT, and the lead Chief Executive for the Sustainability and Transformation Partnership. The ACO is likely to be an NHS body in its new form but with significant commissioning responsibilities unlike current NHS trusts.

What they mean by an Accountable Care System

  • Accountable Care Partnership: The ACP will operate as a single provider for acute, mental health, community, primary, children’s,
    ambulance, wellbeing and social care services, including a range of public, independent and third sector organisations. It will need to encompass providers who sit outside of Cornwall, but serve our local communities
  • The ACP will be led by a leadership team with collective responsibility for the effectiveness of the overall provision system, and a place based budget so that budget and accountability are located where ‘tactical’
    decisions are made.
  • Whilst the ACP will need to operate as a single provider, it will comprise several separate legal entities that jointly commit resources in support of collaborative working and agree to be bound through a suitable legal vehicle (e.g. joint
    ventures, alliance contracting models, prime contractor models, Section 75
    agreements or, alternatively, partial formal organisational integration).
  • However,all entities will work underneath a single ACP Governing Body which would have a responsibility to oversee the development of strong, locally responsive arrangements with the active engagement of local GPs, and provide the assurance route through to regulators on behalf of the provision system.
  • Over time, consideration will be given to moving to a single Accountable Care Organisation, if additional benefits can be realised through moving to this end state.


 Timescales for the Implementation in Cornwall of the Accountable Care System

  • Signing of ACS Accord through the STP Transformation Board By end of August 2017 Cabinet Member for Adult Services


  • Report on phase 1 on the work to develop ACS –covering proposed governancearrangements for commissioning and delivery, iBCF plan and performance measures. Secure agreement to enter into a shadow ACS with Cornwall Council member of the provider collaboration board. 19th October 2017 at Health and WellBeing Board
  • Draft four year financial and business plan report to Cabinet which identifies how the health and social care integration savings in the MTFS will be achieved as part of the development of the ACS 15th November 2017 Cabinet
  • Report to HWBB on priorities for shadow ACS for 18/19 covering a single vision and commissioning strategy (Health and Wellbeing Strategy for Cornwall), jointly agreed commissioning outcomes and KPIs, business plan priorities and measures for the accountable care delivery organisation for 18/19. 25th January 2018 Health and WellBeing Board
  • Report to agree full business case for an Accountable Care System for Cornwall and the Isles of Scilly specifically setting out the arrangements for adult social care; strategic commissioning and support services with detailed implementation plan 7th February 2018 Cabinet
  • Bi-monthly update reports on Shaping ourFuture Programme and the System Reform workstream Throughout 2017/18
  • Health and Adult Overview and Scrutiny Committee Report to Constitution and Governance committee on decision making processes and role of HWBB as part of the ACS 27th March 2018