As the NHS passes its 70th birthday the recent report from the Health and Social Care Committee on Integrated Care could find little wrong with the direction of travel within the health service. While critics might cavil about the threat of further privatization, the Committee argued instead that the service was entering a new phase of collaboration rather than competition. Notions about the Americanization of the NHS were misplaced, due in part to the terminology surrounding Accountable Care Organizations, while the somewhat less than transparent introduction to this new phase had added to the confusion. Such problems could however be remedied by a “clear and compelling narrative” developed by the Department of Health, NHS England and other associated bodies, which would reassure both patients and taxpayers that the path of transformation was sound, sustainable, and in their best interests.
The Committee also argued that clarity could be more readily achieved by developing this narrative from a patients perspective, rather than focusing on systemic transformation. Such a perspective would focus on “how patients experience the health and care services they use”, and that what matters is that providers, whether public or non-statutory, “create coherent and comprehensive services, share information, work together and put patients’ needs, priorities and goals at the centre”. Indeed one can anticipate the content to be apolitical, dull, and with cross-party consensus and a new ‘NHS Assembly’ lending extra layers of concerned neutrality towards the co-design of the forthcoming 10-year plan.
HOMOGENEITY
In order to contest this it’s essential to identify the real guiding narrative for transformation, one which, while not always transparent, is overtly politicized and global in reach. It’s arguable that such a narrative already exists, is securely in place and has been for some time, and seeks to reconstruct healthcare systems to benefit transnational capital. Led by a transnational capitalist class with few, if any, allegiances to domestic staples, particularly re-distributional welfare, the aim is to impose a kind of global homogeneity of healthcare organization. Such standardization will attempt to safeguard and simplify investment strategies, and to embed corporate control of both purchasing and service delivery within rapidly evolving ‘mixed economies’ of care.
Homogeneity also gives meaning to attempts at trade deregulation; the TTIP, for example, would be somewhat limited if domestic systems weren’t fully investor compatible. The use of capitated budgets for ACO providers, for example, is expressly geared towards private investor interests, as the upfront capital can be invested in the global markets, with returns on equity in excess of 16%.
The insistence on fiscal austerity has accelerated such changes, transcribing the demands of financial regimes onto healthcare systems via the concept of sustainability. This not only permits a reframing of what care is to be available, but also a radical reframing of the delivery system. It was no surprise, for example, that the World Economic Forum’s (WEF) year long deliberations on healthcare followed the announcement by Standard & Poors in January 2012 that national healthcare systems must demonstrate sustainability in order for their economies to maintain credit ratings. Workshops held in New York, Berlin, Istanbul, Tianjin, Madrid, Basel, the Hague, and London that year, were, according to the WEF, “remarkable in their consistency of vision”, advocating, for example, delivery from “capital-light settings” using “leveraged talent models” and “low-cost channels, such as home-based models”. In other words, what’s happening to the NHS is being reproduced on a global scale.
It’s also important to identify chains of command within these processes, and, owing to its economic strength, a key role is played by the US. Not only will US corporations be privileged, but also the standard template mentioned above builds upon the country’s main organizational format: that of ‘managed care’. Private insurance-led and with minimal recourse to federal programmes, managed care also involves a range of hospital- or physician-based provider networks. And it’s no accident that prior to his appointment as Chief Executive of NHSE, Simon Stevens led the Global Health Division of the US’s largest insurer, UnitedHealth, and was also chair of the WEF’s Steering Group on system sustainability. The interoperability of transnational and US ambitions isn’t always so clearly expressed.
TRANSLATIONS
As mentioned, the WEF’s reports were released in early 2013, and Stevens’ first main task for NHSE was in producing the Five Year Forward View in late 2014. Conceived as an overall appraisal of the NHS, the centerpiece of the Forward View was the introduction of new care models, namely the Trust-led Primary and Acute Care Systems (PACS), the primary care-led Multispecialty Community Providers (MCPs), and the more radical variant, the system-wide Accountable Care Organization (ACO). Such formats would be test-bedded across England in a series of vanguard sites offering examples of how these models would shape up in practice.
One such example is the South Somerset Symphony Programme. Led by Yeovil District Hospital NHS Foundation Trust (FT), the project is an advanced PACS vanguard in all aspects of the FYFV’s vision, incorporating radical changes in workforce, infrastructure and partnership arrangements. Working relationships have been established with Somerset CCG and Somerset County Council, as well as partnerships with other providers, and commissioners are working on similar approaches for the rest of the county with the aim of establishing a countywide ACO by 2019.
In terms of finding private partners for the new model, the FT was guided by the US-based global consultancy, Oliver Wyman, a company that “serves clients in the pharmaceutical, biotechnology, medical devices, provider, and payer sectors with strategic, operational, and organizational advice”. Private partnerships with the Trust now include those for services in diagnostics, digital services, online booking and management, ophthalmology, and in elective care. The last named is provided by ASI, the international arm of Amsurg, the US’s largest operator of day case facilities. The FT also partners Interserve Prime in a ‘strategic estates partnership’, to develop a wide range of retail outlets as well as a nursing home, GP practice and pharmacy, all of which, according the Trust’s CEO, could be run by the private sector.
Also assisting in the transition to an ACO has been Optum, the UK arm of UnitedHealth. The Trust’s document, ‘Join the Revolution’ is worth quoting in full:
“As (we) move towards an outcomes based contract in April 2017, the creation of an ACO is core to its effective delivery. The ACO model born in the US market is new to the UK, and as such we have partnered with globally experienced Optum who are guiding our journey into this new world. The partnership initially for a 9-month period is helping to plan, design and communicate the way the ACO’s will work, and critically financially model the value of managing a budget for the whole population of Somerset over a 10 year contract period”.
As mentioned, commissioners aim to extend this approach to the whole county, with Optum supporting other peers in the locality. As a Kings Fund document points out, the CCG envisages restructuring its services so that it can play “a more strategic role in overseeing the system, and expects a ‘managed services organization’” – such as Optum – “will sit within the ACO and act as its ‘engine room’”.
TEXTBOOK
While at first sight the scale of change in Yeovil is surprising, a close reading indicates it’s more textbook than anomalous. According to the Kings Fund, Optum, currently “supports GPs and provider groups in delivering new care models, including through offering analytics, actuarial support, decision support for clinicians and support for contracting”. Which, it has to be said, sounds remarkably like a health insurer. One of Optum’s clients is the Modality Partnership, which while it began in Birmingham, now straddles several counties, and is perhaps the leading MCPs vanguard. Some of the new care models “saw strong benefits of partnerships with private providers such as Optum because they could offer capital investment to support transformation, particularly if the government is less able to provide this investment in future”.
Similarly for PACS vanguard sites in Birmingham, Airedale, Fylde and North Tyneside, the Oliver Wyman company helped introduce “proven care models from other countries, customizing them to local needs, and then implementing them”. One of Oliver Wyman’s senior partners, Crispin Ellison, served in the Prime Minister’s Office, where he “identified new care models for health and community care” that “drew on best practice innovation in public and private sectors globally, as well as lessons learned in implementing major change initiatives”.
At a conference held by Wymans in London several months before the publication of the FYFV, all the trusts and CCGs from the above mentioned sites were present, alongside representatives from NHSE, Monitor, 10 Downing Street, and several other authors of the forthcoming narrative on integrated care.
Interestingly Wymans has a regular advert in LaingBuisson’s ‘Healthcare Markets’, the UK’s leading journal for the private healthcare industry. Under the banner ‘Transform Care: Implementing New Models to Improve Care and Value’, the company offers “To build sustainable solutions that are patient/ customer focused, health and social care systems need to optimize outcomes and experience, while delivering on value. We help clients transform care through the development and implementation of innovative, proactive, patient-centred models that address gaps and inefficiencies in our current delivery system”. The narrative used for both private and public sectors is interchangeable.
The company may also invite local NHS ‘leaders’ to its annual conference in Chicago, which brings together CEOs from major corporations – over 50% C-Suite in the blurb – who are “committed to the market transformation that will migrate $1 trillion to new players, new industry segments, and traditional companies that are delivering better health value”. The companies involved in the 2015 event included the insurers Blue Cross, Humana, Anthem and UnitedHealth, as well as various big pharma companies and Walgreens and Wallmart. It also included the CEO of Yeovil Foundation Trust.
ENDPIECE
In a blog to accompany its submission to the Health Committee, the Kings Fund, which also acted as chief advisers to the report, said, “there is no evidence that private providers of clinical services are taking on a bigger role in areas that are furthest ahead in developing accountable care”. It also said that while the proposed ACO contract may in theory open the NHS to companies from the US to compete to deliver care to NHS patients, this was “highly unlikely in practice”. As the examples above attest this is simply not the case. The range of private healthcare provision in Somerset is remarkably extensive, so much so in fact that the vanguard can no longer be considered a public entity. US companies it would appear are not simply offering services, but providing capital investment, acting as brokers for other private providers, and also acting as de facto commissioners of care at a county-wide level. It would appear that the ‘engine room’ of change for the English NHS is firmly transatlantic.
In its conclusion the Health Committee thought that too much emphasis had been place on wider processes at work within the NHS, and had come at the expense of more accessible interpretations of the changes deemed necessary to keep the health service afloat. As such, the Committee argued that there “needs to be a clearer narrative to explain the direction of travel: what are these reforms trying to achieve; what does the end state look like; what are the risks and what the benefits for patients and taxpayers”. There is a clear narrative involved, developed in the meeting rooms and conference centres in Chicago, Davos, and other loci of power, which pursues a US-led transnational agenda. And it’s one that does not aim to benefit patients.