Over the festive period there has been something of a debate as to whether entities that are not NHS statutory bodies, but rather entities that contract with the NHS, can be trusted.  The debate has focussed on the evolving Accountable Care Organisations (ACOs).  For example, Dr Phil Hammond, a doctor, radio presenter and NHS commentator, said,

“I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver.” (via Twitter, Jan 1^st)

I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver. Outsourcing them would be like outsourcing health authorities

— Dr Phil Hammond (@drphilhammond) January 1, 2018

Unfortunately, this brings the position of GP practices under the spotlight.  If this is true for ACOs, is it not also true for GP practices?

There is a fine line between being in the NHS and working with the NHS.  Back in 1948, amidst the protracted negotiations required to start the NHS, a deal was brokered whereby GPs would not become salaried employees, but rather remain independent, providing services via a national contract with the NHS.  This means GP practices provide NHS services, but are not NHS organisations, and “independent contractor” status was born.

Does the distinction between a statutory body and an independent contractor matter?  At first it mattered little, but times have changed since 1948.  In the 1980s the Conservative government privatised some of our national industries, including steel, railways, airports, gas, electricity, telecoms and water.  The NHS survived the cut, but instead the purchaser provider split was introduced in 1990.  Ever since, fears have remained that this was the first step in a plan to privatise the health service, and anything not a statutory NHS body is treated with suspicion.

Over 25 years later, we now approach the end game of the purchaser provider split, in a strange closing manoeuvre whereby the Health and Social Care Act of 2012 seemingly opened the NHS up to more competition, but in practice the NHS itself has closed competition down with a focus on integration through the Five Year Forward View.  Integrating organisations to work together within a fixed budget to improve the health of the local population has been termed “accountable care”.  Unfortunately, accountable care organisations are associated with the US, and fears have developed that they are the new Trojan horse to enable the privatisation of the NHS.

Enter the new importance of “independent contractor” status.  It is proposed that ACOs will contract with the NHS, rather than being statutory NHS bodies (just like GP practices).  This is a pragmatic response to not wanting new legislation (the only way to create new statutory bodies) or yet another top down reorganisation of the deck chairs, but instead wanting to enable and encourage local areas to develop local solutions that are right for them.  Unfortunately, that hasn’t stopped some campaigners from trying to take the Department of Health to court over their introduction.

I have written before about whether independent contractor status will form part of General Practice’s future.  My sense is the benefits (to GPs and to the delivery of health care) outweigh the costs and challenges.  The currency of the new world is trust.  People trust their GP, more than they trust their local NHS organisation, and much more than they trust national (statutory) NHS organisations.  Being a statutory part of the NHS won’t make the public trust GPs any more.

The same ultimately will be true of ACOs.  It is not what you are but what you do that matters, and their ability to build trust with the people they serve is likely to directly impact how successful they are.  Ironically, it is the relationships ACOs develop with their local (independent contractor) GPs that may determine how much their local population eventually choose to trust them.