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Putting the A in ACS

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LGC’s commentary on tensions in the STP process

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Last week’s LGC Summit heard the NHS’s sustainability and transformation planning process described as a necessary evil and the only pragmatic means of attempting to make changes in a system weary of restructuring following the misery of the Lansley reforms.

However, widespread concerns were expressed that councils had insufficient clout to force the health service to make significant changes that could genuinely bring about a more preventative system, especially when it is perennially preoccupied with the need to make savings in the here and now.

A number of attendees noted that it would be impossible for local government, with its duty to balance its books, to run up financial problems on the scale of those in the NHS. “Financially bust” was one chief’s description of his local health economy. There was dismay that while some clinical commissioning groups were fining councils for delayed transfers of care, the health service was not itself co-operating, or was too fractured to co-ordinate itself to be radical.

The LGC Summit is held under Chatham House rules, meaning we can tell no more. However, the past week has seen such tensions between health and local government over spending and accountability played out in a spat between Leicestershire CC, Leicester City Council and Rutland CC and the health bodies that are all part of the same STP.

A report prepared for the University Hospitals of Leicester Trust’s board said a plan to create an accountable care system would be considered by nine health and care bodies in the area this month, including the three councils.

The report said: “This is not about ‘whether’ an ACS but when”, indicating surely that all organisations were singing from the same hymn sheet on the move to an ACS.

But evidently, they were not.

Leicestershire CC chief executive John Sinnott told LGC the paper prepared for the hospital trusts was incorrect. He said at the last STP leadership team meeting “it was made clear that there was no agreement from the local authorities to progress the paper through their decision making processes”.

Yesterday, LGC and Health Service Journal reported that the other two upper-tier councils were equally frustrated.

The councils have criticised the absence of detailed plans to tackle the £399m financial gap outlined in the STP, and the failure to establish accountability and governance frameworks.

There was also concern over the performance of the acute trust, which has been ordered to improve by NHS Improvement after some of the worst A&E performances in the country.

Rory Palmer (Lab), deputy city mayor of Leicester City Council, said: “Our patience is being tested to breaking point. It is likely our very serious concern will be formalised. It is likely we will be contemplating whether it is right for our officers and teams to remain engaged with the programme.”

Richard Clifton (Con), a cabinet member and chair of Rutland health and wellbeing board, said Rutland CC shared the concerns.

Mr Sinnott expanded on his complaints about accountability in an LGC column.

“The recent imposition of accountable care systems as the only way forward for STPs presents fresh concerns around the involvement of the local authority and respect for its role,” Mr Sinnott wrote.

He charted what he saw as the declining regard for councils in the reform process. Mr Sinnott wrote that NHS England in 2016 asked all health and care organisations, including councils, to come together to form plans, but that by the time the Five Year Forward View Next Steps document was published this March, “local authorities were seen as an optional partner” and the STP project had become one mainly concerned with “how local NHS bodies work together” and with NHSE.

Mr Sinnott contended that without the accountability of a health and care system to the local population, as opposed to the automatic accountability to central NHS bodies, STPs or ACSs were “courting a serious risk of failure”.

He called on all partners to pause in the process, because ACSs “will not be the answer to NHS pressures this winter” in any case, and to assess the model’s effectiveness and accountability before going any further.

But even if all partners did pause, adding more local accountability to the mix would not necessarily be without challenges. As King’s Fund fellow Nicholas Timmins wrote for LGC earlier this month, this could “strain the tension between the public’s desire for localism as well as universalism to breaking point”.

So councils are struggling to make their concerns heard, the NHS is struggling to balance its books and moves to make a radical transition to a more preventative, service-user centred care system is tempered by financial and political constraints. When deliberating about how places can ensure systems are accountable, financially sound and effective, as the old joke goes, one wouldn’t start from here.

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