Is the NHS converging to accountable care systems?

Chris Ham

Chief Executive

6 July 2017

What the electorate said

› Hope not fear

› No hard Brexit

› No further austerity

› No single party commands public confidence

Uncertainties

› How long before the PM is challenged and replaced?

› Can a pact with the DUP be agreed and will it stick?

› When might a second election take place?

› What will Brexit mean for the economy and public finances?

Implications for the NHS

› A less damaging Brexit?

› More funding for the NHS and social care?

› No controversial legislation

› Political caution about service reconfigurations

› Green paper on social care

More of the same – for now

› NHS England’s position is likely to be stronger as the government’s position has become weaker

› The five year forward view remains the direction of travel for now

› STPs and accountable care organisations or systems will receive greater attention

› Work to improve financial and operational performance will continue via CEP and other means

› Workforce challenges are likely to increase and may be accentuated by Brexit

Another reorganisation?

› The organisation of the NHS is complex and fragmented and accountabilities are diffused

› There is no appetite for a top down reorganisation to streamline and simplify

› Some changes are happening bottom up e.g. CCG mergers and alliances and creation of hospital groups

› There is debate about streamlining the work of national bodies

› STPs are an uncomfortable but necessary workaround that are here to stay

› They are an example of the place-based systems of care we have argued are needed

Competition and collaboration

› STPs require collaboration – the 2012 Act was designed to promote competition

› The NHS is made up of statutory organisations who are now being asked to work in non-statutory systems

› Regulation is focused on organisations and has been slow to adapt to place-based systems

› Most STPs are aggregations of smaller systems that often have greater coherence than STPs themselves

› STPs got off to a difficult start and set out ambitious and wide ranging plans

› There is much to be done to secure wider engagement and to move from planning to implementation

Accountable care organisations

› The language of ACOs has emerged recently in the US on the back of Obamacare

› ACOs bring together a number of providers to take responsibility for the cost and quality of care for a defined population within an agreed budget

› ACOs take many different forms from fully integrated delivery systems to alliances of diverse providers

› ACOs build on a much longer history of well known integrated delivery systems like Kaiser Permanente

› Early evidence on impact of ACOs on cost and quality is mixed and sometimes negative

› Evidence on established integrated delivery systems is more positive

What ACOs do to deliver improvements

› They seek to reduce cost and improve quality by reducing hospital use

› Approaches include understanding the population served and stratifying by risk

› Using case management to support people with complex needs at high risk

› Improving flow of patients in hospitals through use of hospitalists and discharge planners

› Following up patients post-discharge through telephone contact and care in people’s homes

› Supporting people to self manage and maintain health and wellbeing

The spectrum of integrated care

Important ingredients of ACOs

› Responsibility for defined population

› Aligned incentives e.g. population based budgets

› Accountability for outcomes

› Information sharing and ideally a common electronic record

› Knowing the population and providing care proactively to people most at risk

› Clinical engagement and leadership

› ”It’s more sociological than technological”

The hard bit

› The ingredients are a necessary but not sufficient condition

› We are working in a system that was not designed to support integrated models of care

› Areas of England that are making progress are often doing so despite the system

› The actions of national bodies can get in the way

› Canterbury DHB’s vision of ‘one system one budget’ was a powerful motivator and could be useful for us too

The voice of primary care

› In Canterbury this was heard through Pegasus, a federation representing most of the general practices

› Emerging ACOs in England are working to find different ways of engaging with primary care

› The distributed nature of general practice and different views on independence and involvement play into this

› MCPs are another route for establishing ACOs starting from general practice but face their own challenges

Examples in England

› Salford

› Northumbria

› Morecambe Bay

› South Somerset

› Wolverhampton

› And many more

Technical challenges

› The organisational form for ACOs and ACSs

› The contractual mechanism

› The funding mechanism

› Risk sharing

› The role of commissioners as well as providers

› Regulation

Relational challenges

› Are organisations and their leaders willing to work in this way?

› Do they trust and like each other sufficiently?

› Are they prepared to leave competition at the door and embrace collaboration?

› Are NHS boards willing to give up some of their sovereignty for the greater good?

› Will regulators work in a way that supports ACOs and ACSs?

› Can the NHS and its partners develop the system leaders needed?

Finally

STPs and ACOs are not panaceas

They are a stepping stone in right direction

Place and population should be the focus

Prevention is key (as Wanless told us)

ACOs have to be ‘made in’ each place

Legislative changes will be needed at some point