Next Steps of the Five Year Forward View (March 2017) sets out plans for the transition of the NHS to population-based integrated health systems. This will be achieved by the evolution of Sustainability and Transformation Partnerships (STPs) into ‘accountable care’ models.
Next Steps defines two types of accountable care models:
– Accountable Care Systems (ACSs)
– Accountable Care Organisations (ACOs).
Before exploring what is meant by the ACS and ACO, it is worth considering what is meant by ‘accountable care’ in general terms. Accountable care models evolved in the United States from existing integrated care systems. They are more easily defined by a series of common characteristics than by a fixed definition – a commonly held definition of accountable care is a model which brings together a variety of provider organisations to take responsibility for the cost and quality of care for a defined population within an agreed budget (for example a whole population budget).
NHS England views the development of accountable care models as an evolution into ACSs and then ultimately into ACOs. An ACS will allow STP partners to work together to integrate care and develop collective responsibility for resources and population health. An STP that develops into an ACS is also expected to get greater control and freedom over the health system in their area, working closely with local government. Whereas becoming an ACO will be the end objective in the evolution of STPs in some areas, where commissioners will contract with a single organisation for the great majority of health and care services in an area.
NHS England rightly acknowledges that one size does not fit all and STPs are continuing to develop at different speeds with different arrangements for STP leadership and accountable care.
We have co-produced with NHS Providers a guide about accountable care which identifies seven key steps for STP partners considering putting in place accountable care models. We summarise these steps below:
Step 1: Phasing
NHS England recognises that the transition to accountable care is complex and requires careful management of risk. In particular, ACOs are likely to take time to establish given they will be dependent on the award of whole population budgets under long term contracts. As a result, staged implementation will be necessary, starting with the evolution of existing care models and organisational structures towards ACSs.
Step 2: Partners
STPs may decide that their area is suited to one accountable care model or a number of different models. Early clarity about the key partners in each model will be essential. Some partners will be obvious, such as commissioners, GPs and acute and mental health trusts. Others will be less obvious, such as voluntary sector and private sector partners responsible for delivery of NHS and local authority funded care.
Step 3: Governance
Some of the most substantial risks to developing accountable care models lie in transition as STP partners seek to coordinate decision-making, since STPs are not legal entities in their own right and have no powers to make decisions. Partners need to consider carefully how to put in place effective structures to facilitate decision-making. And in due course, they need to consider how decisions will be made in the accountable care models that partners put in place – for example, they need to consider whether leadership by a single organisation will make decision-making easier and reduce governance risks.
Step 4: Contracting
NHS England anticipates that accountable care models will operate under accountable performance contracts. These contracts are likely to be based on the existing and evolving suite of contracts produced by NHS England for new care models. They will be long term contracts which incorporate new payment models such as whole population budgets, improvement schemes and gain/loss share agreements. In time, commissioners may be able to award a single accountable care contract to an ACO, but until then partners will need to operate through a network of different contracting arrangements including existing contracts and new contracts.
Step 5: Funding
Delivering integrated services for an accountable care footprint will ultimately require whole population based funding. NHS England has indicated its intention to put in place such arrangements and indeed whole population based funding is already in place in a small number of locations. Moving to new payment models will be complex and may need to be phased in over time.
Step 6: Organisational form
An accountable care model can take many different organisational forms ranging from loose alliances or partnerships in which organisations retain their own autonomy but agree to collaborate to fully integrated networks of hospitals and other providers. An ACO is likely to involve a greater degree of organisational integration than an ACS. There is no ‘right answer’ to the question of which organisational form best suits a particular model – the much-quoted ‘form follows function’ really is true here.
Step 7: Enablers
Finally, partners need to consider the key enablers that will be required to deliver accountable care, as identified by Next Steps – workforce, safer care, technology and innovation. For further details about the key considerations for each of these steps please see ‘A seven step guide to accountable care’ available here.