George Orwell, Politics and the English Language (1945)
With the half-life of NHS policies now measured in days and weeks, it was with weary resignation, rather than surprise, that the recent demise of accountable care, in all its splendid variants, was greeted. The announcement by NHS England that “integrated care systems” are now the preferred model will prompt urgent NHS discussion and activity: how does accountable care differ from integrated care; to what extent is a system different from an organisation, or a partnership; where are the successful examples of integrated care systems from which we can learn? The “eliminable vagueness” and fluidity of NHS policy terms such accountable and integrated care (combined as required with organisation, system, and partnership), enables their significance and meaning to change with context. Capable of multiple interpretation, they confuse critics, resist refutation, and distract from threats to the fundamental principles of the NHS – a universal, comprehensive publicly-provided, publicly-funded, service free at the point of delivery.
In an era of fast policy, the detail of any policy announcement is of secondary importance to its intended political purpose. The re-branding of accountable care enables an irrevocably tarnished policy to be relaunched, political opponents to be wrongfooted, and the central moral and political questions raised by the policy to be side-stepped. The insertion of accountable care into the NHS can be understood as emblematic of just such a fast policy process, in which specifically neoliberal policies circulate globally and are adopted and adapted locally through a network of intellectuals, special advisors, policy gurus, and think tanks, harnessing the gullibility of politicians seeking a quick fix and exploiting threatened public-sector managements.
Aside though from their political content, neoliberal ideas such as accountable care can also be identified by their fluidity under challenge, their malleable and multiple interpretation, and mobility and resistance to definition, all of which makes refutation difficult. With an ever-expanding lexicography (LCO, ACO, ACS, ACP, MSP, PACS and so on…) and a multitude of conflicting interpretations and understandings, confusion abounds. For example: accountable to whom (NHS England, the Department of Health, Jeremy Hunt?); which care model? As Allyson Pollock has commented, the lack of clarity surrounding accountable care hampers a full appreciation of the nature and scale of the changes.
Accountable care was assailed by an alliance of GPs, NHS staff, action groups, and judicial reviews. This had the effect of making redundant its effectiveness as a disruptor, and the need for a relaunch became inevitable. By raising the spectre of the Americanisation of the NHS, accountable care as a policy vehicle had, in any case, done its job, to be replaced by the more palatable, consensual, and virtuous notion of integrated care, an appropriately vacuous phrase for a policy which, devoid of intellectual content, bereft of supporting analysis, and unsupported by evidence, defies understanding. Integration of what? Care of whom? Which system, where?
And so welcome to the world of integrated care systems where everything and nothing has changed. Consider this. The disruptive Health and Social Care Act (2012) laid the foundations for the competitive procurement of NHS services and, strengthened by the Procurement, Patient Choice and Competition Regulations (2013), the Public Contracts Regulations (2015), and the Integrated Support and Assurance Process (2017) has cemented (through legislation) processes of open procurement and competitive bidding into the architecture of the NHS. Expedited by the “any qualified provider” test, the application of competition law, and the diffusion of accountability (which has made effective public challenge more difficult), local markets in healthcare have been exploited by private providers, specifically in community services and primary care. Marketisation of the NHS is happening here and now, and whether future policy favours integrated, or accountable, care is irrelevant, it is a straw man, intended to draw our eye away from more fundamental change.
Based on these pervious changes, further structural reorganisation, whether under the banner of accountable or integrated care, (or whatever follows next!), increases the likelihood of greater private sector involvement in the NHS. Moreover, as I have argued elsewhere, fragmentation of the NHS into discrete, unrelated parts exacerbates the marketisation of the NHS and favours private involvement.
At the highest political levels, clearly this idea is not unthinkable: the Prime Minister has refused to rule out American involvement in the NHS as part of any transatlantic future trade deal, whilst Jeremy Hunt has consistently refused to comment on the prospects for future private sector involvement. Attempts may be to ensure NHS leadership but when a bidding process is commenced the outcome cannot be controlled and private companies can bid low to win contracts. Private providers, almost without exception, will bid low to win contracts (the loss-leader model – see ) and gain market-entry.
The language of health policy is important as it is constitutive, not just neutrally conveying ideas and thoughts, but building new social realities and dismantling old ones. On one level, the renaming of accountable care, is a simple label-change designed to present the policy in a more appealing wrapper and to create a new, consensual, positive reality: who dare argue against “integration” or “care” as worthy goals? However, for those pursuing a neoliberal reform agenda, it is a conscious political act. It is intended, firstly, to create a new, consensual, positive reality of NHS reform. The second purpose is to obfuscate and confuse – the protean nature of these terms is their very attraction – and to distract from an underlying political objective – marketisation – that dare not speak its name.
Against a backdrop of the worst winter crisis in NHS history, record financial deficits, and ever-declining NHS performance, new market-based, or integrated care system-based solutions (to give them their current name), are being proposed under the guise of ever-more seductive and attractive language. Future research, whilst examining the impact of these specific proposals upon the founding principles of the NHS, should be alert to the fact that accountable care, integrated care, and whatever follows in the next half-life, are not and never have been the true objective or the final destination
About the Author: Adrian Mercer Ph.d, is a former primary care trust chief executive, NHS policy researcher, and occasional lecturer in health and social care policy. Based in Devon, he is currently researching and writing about NHS developments, including privatisation, democracy in the NHS, and digital politics. He is on twitter @adeindevon