Ministers' under the radar NHS reforms are fuelling public anxiety | Richard Vize

The war over the future of the NHS is being fought on multiple fronts. Campaigners, the Labour party, the government, NHS England and even Stephen Hawking are locked in combat over the structure, funding, transparency, accountability and legality of the current wave of reforms, along with the never-ending fight about privatisation – real or imagined.

The famous physicist has joined campaigners in a high court bid to block the introduction of accountable care organisations to oversee local services without primary legislation, arguing they could lead to privatisation, rationing and charging.

Meanwhile, the shadow health secretary, Jon Ashworth, has tabled a Commons early day motion after the government announced plans to amend regulations to support the operation of accountable care organisations. Ashworth argues that they are a profound change to the NHS that should be debated in parliament.

Accountable care – a term imported from the US, where it plays a key role in Obamacare – can take many forms, but it typically involves an alliance of providers with a fixed budget collaborating to manage the health needs of their local population. NHS England wants to see sustainability and transformation partnerships (STPs) evolving into accountable care systems in which integrated care supports good physical and mental health.

In June, NHS England announced that eight areas would be leading the accountable care drive. Greater Manchester is also adopting this approach, and many others are starting to use the accountable care language.

Accountable care has the potential to address many of the criticisms the most vociferous supporters of the NHS have made for many years. It goes a long way to replace competition with collaboration, and the NHS England chief executive, Simon Stevens, said it could mark the end of the infamous purchaser/provider split, which weighs down the health service with costly and often pointless bureaucracy.

Locally led, integrated systems are essential if we are going to shift the NHS from a 1970s-style hospital service to one that provides a community-based health and wellbeing service. Pooling budgets across the local area is not a ruse to disguise cuts. It is the most effective way to manage public money, irrespective of the level of funding.

The court case confuses the issue of how the NHS is organised with its funding and the role of the private sector. These are three different issues.

But the legal basis for accountable care is shaky. Faced with the wreckage left by Andrew Lansley’s infamous 2012 reforms, NHS England introduced STPs because trying to plan services through more than 200 clinical commissioning groups was never going to work.

As demand climbed, funding flatlined in the aftermath of the 2008 crash and managing long-term conditions became the dominant challenge; it was imperative to move from competition to collaboration and set a long-term goal of population health management. That is where accountable care comes in.

STPs and accountable care are operating under legislation meant for clinical commissioning groups – so collaborative systems typically serving 1.2 million people in which local government and all parts of the NHS have a say are underpinned by a legal framework for GP-managed competition overseeing populations of 250,000.

This is such a precarious legal balancing act that the 2017 Conservative manifesto promised to tidy up the legislation and regulations. But introducing an NHS bill now would be political harakiri for Theresa May, and most health service staff would prefer legal ambiguity to yet another round of organisational upheaval that would inevitably follow legislation.

So the choice is to either continue to find legal bodges to allow the NHS to collaborate and plan or – if the high court challenge succeeds – to return to the Lansley dream-turned-nightmare of full-blooded competition.

But although the thinking behind the legal challenge is muddled, that campaign and Labour’s early day motion highlight the major problem: a profound change in the management and leadership of the NHS is being introduced without informed public and parliamentary discussion.

The new approach has many strengths, but introducing it under the radar only serves to feed anxieties and misconceptions about the objective. NHS England needs to get the discussion about accountable care out in the open.

• Richard Vize is a public policy commentator and analyst

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