Five things you need to know about changes to the NHS in Cornwall

Some proposed changes are common sense and others are controversial, but if you don't know the difference between an ACO and an ACS, you might end up throwing the baby out with the bath water!

 Most people are concerned about the future of the NHS, but even some of our decision makers are confused about the details!

Most people are concerned about the future of the NHS, but even some of our decision makers are confused about the details!

I've been keeping a very close eye on the plans to reform health and social care in Cornwall which have been emerging over the past year. The NHS is a fiendishly complicated organisation, and during 2017 we were introduced to Sustainability and Transformation Plans, Shaping Our Future, Co-production, Accountable Care Systems, Integrated Strategic Commissioning, Accountable Care Partnerships and Accountable Care Organisations! It's no wonder most people are confused...

So, here are five things you need to understand about the proposed changes to health and social care in Cornwall:

1) More money is essential, but money alone will not save the NHS

Some protesters have been opposing any changes to the system, saying that all we need is more money. Every single witness to the recent Cornwall Council inquiry agreed that change was essential. The current system is in crisis, and even if there was more money on offer, there is a real shortage of doctors and nurses in the country to fill any new vacancies. It's not a case of "either/or"; We need both system reform and a fair funding settlement.

2) Changes to front-line services are being designed from the bottom up

Most changes to the NHS fail because they are dreamed up in Whitehall and then imposed on the workforce from the top down.

Liberal Democrats believe that the best ideas come from the bottom up. That's why I'm so pleased to see that improvements to services in Cornwall are being led by patients and healthcare professionals who work on the front line. For example, nurses and patients in West Cornwall have created the "Centipede Club" at Ludgvan Community Centre. This has enabled patients to receive first-class treatment for their leg ulcers AND to socialise with one another. The club also benefits the NHS because it allows the nurses to treat lots of patients in one place without needing to travel to their homes or take up space at the local GP surgery.

Ideas like these are emerging all across Cornwall. Middle managers are helping to replicate the successful projects and senior managers are finding ways to ensure that they can be sustainably funded.

Small, uncontroversial changes like these are already taking place. Bigger decisions such as upgrading some Minor Injury Units and possibly closing others will not be made until there has been a public consultation later this year.

3) Cooperation between providers is better than competition

In 1990, the Conservative Government created the "NHS Internal Market", meaning that each hospital, ambulance service and GP surgery had to act as a "business", competing with other parts of the NHS to see who could deliver services at the lowest price. This soon led to the private sector taking on contracts for cooking, cleaning and maintenance in hospitals, and eventually expanding into providing medical services such as hip replacements and out of hours GP services.

Later, the Labour Government changed the law, making it easier for private companies to take over more of the NHS. Managers were told that they had to open up their contracts to "any willing provider", meaning that even if the NHS provider was doing a good job, they could lose the contract if a private company offered to do it more cheaply.

Many campaigners say that these two reforms undermined the core values of the NHS as a public service run in the best interests of patients.

In 2007, when I worked for Falmouth & Camborne MP Julia Goldsworthy, we campaigned for a change in the law to allow contracts to be judged on their "social value" (how they help the environment, the community and the local economy). The Social Value Act became law in 2012 meaning that Councils and NHS Commissioners no longer have to award contracts purely on commercial terms.

Some areas have been quicker than others to make use of the Social Value Act in the way they award contracts for Health and Social Care. The Social Value act makes it it harder for private companies to take over NHS services, and areas which use it have seen an increase in cooperation between providers. In the past, it made sense for providers to improve their own performance by "shunting costs" onto others (e.g. Community Hospitals being slow to take patients from Acute Hospitals). If these new powers are used wisely, they can have the opposite effect, rewarding providers who can show that they are working collaboratively with others.

Cornwall is finally catching up with other parts of the UK by using these powers to encourage NHS providers to get together and provide more joined-up services which are designed around the needs of the patient.

4) Integrating commissioning will give Cornwall's patients a stronger voice

The next barrier to delivering joined-up services is the fact that there are FOUR separate "buyers" (known as "commissioners"). Hospital care, community care (i.e. nurses visiting patients at home) and patient transport are funded by NHS Kernow, whilst GPs, dentistry, pharmacy, opticians and specialist services for rare illnesses are funded by NHS England. Cornwall Council and the Council of the Isles of Scilly are responsible for funding social care (home care, care homes, supported living and children's services) and public health (e.g. school nurses, health visitors and substance misuse programmes).

Each of these four "commissioners" is given a fixed budget by Central Government, based a formula which gives Cornwall a lower funding figure per head than any other area in England. Cornwall's population is older and poorer than average, but if they need more medical attention, we've got to find the money from within our own budgets! This is known in the NHS as "local accountability", but I believe that true accountability rests with those who set the budget, i.e. Central Government.

If these four commissioners can work in a more joined-up way, there could be several benefits:

  • They can consider the big-picture when commissioning services (e.g. spending more on home-care for patients leaving hospital can improve the availability of hospital beds for other patients who need them).
  • They will be in a better position to award contracts to partnerships of providers who are collaborating to offer more joined-up services which span the different areas covered by the various commissioners.
  • At the moment, some providers take money from commissioners and then refuse to provide details of how it is being spent! By joining forces, the commissioners should have a single, strong voice to stamp out this kind of behaviour.
  • At the moment, it is too easy for each commissioner to blame the others for funding shortfalls. It's also easy for the Government to blame us all for not making the best use of what we've got. Creating a single, integrated commissioner would make it easier to move money around the system to where it can provide the greatest benefit. It will also allow Cornwall to speak with a single voice in negotiating a fair funding deal from Central Government.

I have just taken part in an inquiry examining the options for integrating commissioning in Cornwall. You can see more details here.

5) We can say yes to all the above, but still say no to an ACO

Much of the concern raised on social media about changes to the NHS is specifically to do with ACOs. I am very happy to accept that there are potential problems with ACOs (as well as potential benefits) and I agree that they should not be introduced until:

  • they have been properly debated in Parliament
  • there is a guaranteed long-term funding plan for health and social care
  • we have seen how they work in other parts of the country
  • there has been a full public consultation in Cornwall
  • there is a vote by the full Cornwall Council

These things have not happened yet, so I do not support an ACO in Cornwall.

Fortunately, nobody is proposing an ACO for Cornwall! Anyone who thinks that the Council is about to vote for an ACO should check out this article explaining the difference between an ACO and an integrated commissioning structure.

Some people who DO know the difference have said that they are still concerned because the integrated commissioning structure is the first step on a slippery slope which will inevitably lead to an ACO being forced on us later. I have raised this point with several witnesses during our inquiry and have been given a very clear answer:

Creating an integrated commissioning structure does NOT mean you have to become an ACO. They are two separate questions. You can say yes to integrated commissioning now and still have complete control to say yes or no to an ACO later.
— Ned Naylor: NHS England

Of course, it's always possible that the Government will change their minds later and force us to create an ACO, but if they're going to behave like that, there's not much we can do to stop them anyway. If we refuse to make any changes now in the face of overwhelming evidence that change is necessary, we probably make it easier for them to justify imposing changes upon us later.


I hope this explanation has helped you to separate some of the tangled threads in the conversation we're all having about protecting and improving our health and care system. There is lots more information in my other articles, and I'm always happy to discuss these issues if you want to call me on 07734434164.

But please don't feel you need to ask me to vote against an ACO this week, because I was never going to do that in the first place!