ACS Inquiry – The Results Are In. Bet you can’t guess which option they chose

The Inquiry was set up by the Council to find the best option to develop an integrated system of delivering health and social care


The Accountable Care System Inquiry has released a summary of its findings and recommendations ahead of the full presentation at Monday morning’s Health Scrutiny Committee.

With the last session held on Wednesday afternoon the ever efficient Leanne Martin, Democratic and Governance Officer at the council deserves a medal for preparing the document ahead of Monday, and allowing committee members time for proper scrutiny.

The Inquiry was set up by the Council to find the best option to develop an integrated system of delivering health and social care. It held four sessions of witness evidence and was tasked to choose between one of six options, that were increasing levels of integration.

Option 1 was do nothing and carry on as we are. With our current system on the edge of crisis and bad inspection reports coming out far too frequently this was never an option. In fact, say it’s supporters, the whole reason for setting up a ACS as quickly as possible is to solve these ongoing problems.

The six options that were under consideration by the ACS Inquiry panel

Option 6 was on the other end of the scale and the preferred option of NHS and Council bosses. Integrate as much as possible and get on with it. Yes, there’s a rapidly dwindling budget so you’ve got to be as clever as possible with the little money you have.

It’ll be no surprise to observers of this process that the Inquiry will recommend the Council proceed with Option 6.

The report to Monday’s meeting explains why they reached their decision

“The Panel felt Option Six carried the least risk to the authority of the options because it, in theory, would retain both democratic oversight and clinical leadership. However, the risks associated with any option taken forward would need to be identified as a business case is developed and a shadow function formed”.

“In the presentation by Kate Kennally on the 10 January 2018, the Panel were informed of six options which could be developed to meet the proposed function, along with the relevant assessment criteria. On the 15 January 2018, Helen Childs and Caroline Court provided Members with information relating to the scoring of the options that had been undertaken by an officer group formed from across the four organisations involved. Jonathan Price confirmed the view of Cornwall Council officers at the meeting held on the 31 January 2018. The officer analysis recommended that Option Six be developed. As the amalgamation of evidence emerged, the Panel agreed with this recommendation”

The process will now involve a presentation to the Health Scrutiny committee on Monday followed by a vote by the Committee to formally recommend to Cabinet the preferred option. Cabinet then votes on it, maybe as soon as their March 28th meeting and then Full council at some point thereafter.


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The Shadow partnership and system will operate for a year to see how it goes and further develop working practices at which point (assuming this steamroller is not stopped) it will go live with a more formal arrangement.

The inquiry agreed that the ACS should be evolutionary aswell as revolutionary. There will be ‘gateways’ to achieve and go through before proceeding to the next level

The Panel accepted that this option was not without concern, as identified in the recommendations; but felt that “they could support the direction of travel and were confident that as a long-term goal, the integrated strategic commissioning function as a collaboration of the four organisations would be beneficial. There would need to be an evolutionary approach in developing this option, this view was reaffirmed by the evidence provided by Steven Pleasant and his experiences in Greater Manchester. If a gateway test is not met by a target date, it should be the timetable that is flexible, not the test standard

The panel recognised that the submissions from the public, from Healthwatch Cornwall and from workforce representatives demonstrated the significant amount of public concern regarding the development of an accountable care system in Cornwall. The panel’s recommendations admits “The system should not be afraid to share its views and engage with those who have concerns”.

Lib Dem Inquiry Panel member Cllr Colin Martin told Cornish Stuff that he had wanted to include reference to fairer funding in the report but was blocked by the Conservatives.

The report concedes “Funding whilst a contentious issue and beyond the remit of the inquiry was raised as a matter of concern. The Panel noted that whilst funding was a driver for change, it was not the only driver, there appeared to be a desire to ensure strengthened strategic commissioning would drive improvement and increase accountability in the system. Witnesses had acknowledged that additional funding alone would be unable to resolve the weaknesses in the system highlighted by the Care Quality Commission”.

Cllr Colin Martin

Cllr Martin told us “I wanted to include the phrase ‘The overwhelming majority of witnesses agreed that these reforms would only deliver improved outcomes for Cornwall if they were accompanied by significant extra funding from central government in order to address NHS deficits and unfair funding formulae’ but it was blocked”.

“Watch the webcast of Monday’s meeting and you’ll see it’s the Lib Dems who oppose Tory attempts to censor the inquiry report. Witnesses said integration will give Cornwall a stronger voice in calling for fair funding, without which any reform is doomed to fail. I tried to put this in the report but the Tories blocked it, claiming it was “beyond the terms of reference”. I’ll set the record straight on Monday”

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Cllr Martin told us that most concerns raised with him by the public related to creating an ACO not an ACS (see below). “The inquiry has confirmed that we are not creating an ACO and will not be forced to do so – all witnesses agreed that “doing nothing is not an option”; even with more money, the system needs to change”

After Cabinet has rubber stamped this ‘direction of travel’ a more detailed Business Case will be drawn up.

The Council’s report addresses the legal compliance to Monday’s committee meeting, and confirms a vote at Full Council, when it says

“The Inquiry Panel intended to ascertain how democratic control and clinically led commissioning could be retained however, without further information on the form and function this was difficult to achieve. This is an area that the Inquiry Panel requires further information.”

It is recognised that should Cabinet decide to support the integration of health and care services through an Accountable Care System, then a Council decision will be required for constitutional and budgetary purposes”

As Cornwall’s  ACS has been developed many people have been suspicious about the pace of change and have asked ‘What’s the rush?’

“The Panel observed that there was apprehension over the timescales being proposed. It was considered that whilst there should be a pace of change set, this should not be at the expense of ensuring all aspects of the business case are successfully tested. There was no required timescale set nationally and the system in Cornwall needed to undertake the process at an appropriate pace for itself”.

It also addresses the current judicial review into Accountable care Organisations, the report confirms the point that the current proposals in Cornwall are not for an ACO but for an ACS.

“There has been publicity about a judicial review challenge to the decision by NHS England to proceed with Accountable Care Organisations in England. It is important to note that the recommended option in this report does not relate to the creation of an Accountable Care Organisation nor does it commit the Council to anything more than the further development of a business case for any strategic commissioning board. As identified by the Inquiry process and included in the recommendation 3 the terminology used ‘Accountable Care System’ has become confused with ‘Accountable Care Organisation’. The recommended option does not relate to the creation of an Accountable Care Organisation and is for the development of an outline business case to consider the integration of strategic commissioning through a joint committee or board. It is therefore considered that the judicial review challenge in respect of the consultation process for Accountable Care Organisations in England does not have any direct implications if the proposed option is accepted for recommendation”

If you’ve just taken all that in then you can forget half of it already as the Panel will recommend that the term Accountable Care System is not used in future as it causes too much confusion!

They also don’t like ‘vehicle’ to describe the partnership, nor ‘shadow’ to describe the test phase. “The Panel suggested that a more appropriate description of the developmental phase be found that all partners could be comfortable with”.

Any changes upstairs won’t affect employees who will continue to be employed by the individual organisations that will make up the partnership.


Accountable Care System Inquiry Recommendations

Recommendations to Cabinet that:

1. Developing an integrated strategic commissioning function for health and social care should be endorsed as an enabler to aid the delivery of a joined-up health and care system and that option six should be agreed as the direction of travel.
2. As this is a new and untested way of working, the recommended approach is that the transition period (described as shadow working) should be developmental and incremental, testing, reviewing and refining the emerging model. The outline business case should provide clarity on the following:
i. Details of the proposed form of a new commissioning board;
ii. How democratic accountability and clinical leadership will be retained be explicit;
iii. Clarification of the separation between strategic and tactical commissioning;
iv. How the parameters set by Cabinet are met through this proposal;
v. Details of the proposed gateway criteria for each phase, metrics, assessment / assurance process and governance for approval process within the council;
vi. Mechanisms for ensuring trust and confidence between partners are maintained;
vii. The scope of strategic commissioning, including children and young people services, specialised commissioning and primary care.
3. The inquiry panel also received evidence that demonstrated the need for improved communication regarding the wider Accountable Care System proposals and the development of an Integrated Strategic Commissioning function and recommend the following:
i. Proactive communication to the public using clear and consistent messaging explaining the Accountable Care System and the Integrated Strategic Commissioning function;
ii. The language used is changed to reduce confusion, i.e. that the term Accountable Care Systems is not used as this is associated with Accountable Care Organisations and that the term ‘vehicle’ in describing the joint board / committee, is not used as this could be interpreted as a new organisation.

Recommendations to Committee
4. An inquiry process be held to consider developing proposals for provider change
5. The Accountable Care System Inquiry (Integrated Strategic Commissioning) Panel undertake a review process as the business case is developed
6. The Health and Adult Social Care Overview and Scrutiny Committee receive timely updates on the performance and progression of the developing plan in order to maintain effective challenge and scrutiny.

The Full report is here

Image by Mark Zezza


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