The changing landscape of health and social care

Accountable care in the NHS

Next Steps on 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. So what is accountable care, what will it look like in the NHS and how will it affect smaller providers such as charities and social enterprises?

Next Steps defines two types of accountable care models:

  • Accountable Care Systems (ACSs)
  • Accountable Care Organisations (ACOs)

Before exploring what is meant by these terms 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. 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.

Amid all this are both opportunities and threats for social enterprises operating in health and social care. But don’t sit on your hands. These changes are already underway and are expected to accelerate very quickly.

So what are the changes?

The Five Year Forward View published in 2014 set out plans to meet the well-trailed challenges faced by the NHS (rising demand, ageing population, higher costs etc). To deliver services more effectively and ensure better integration or joining-up of various health and care services the NHS has adopted the principle of ‘place based systems of care’. To this end, it has divided England into 44 STP regions.  Each of these regions has developed a plan for delivery of integrated services across its area.  Most STPs intend to develop ACSs or ACOs as a way of ensuring partners work together to integrate care and develop collective responsibility for resources and population health.

This will have implications for all providers of health and care services including charities, social enterprises and Public Service Mutuals (PSMs).   In response to STPs, commissioners are likely to start awarding ACO contracts which encompass many of the community services which have up to now been held through standalone contracts, including many provided by PSMs. These contracts may be long-term (up to 10 years) with values running into billions of pounds. They will have to be advertised but may or may not end up being subject to competitive tender processes.

The contracts may include a requirement for a lead organisation to coordinate all services under the contract, not just those services the organisation will provide itself. In most areas, the local NHS Trusts and Foundation Trusts are looking to take the lead on these contracts, working in partnership with GPs and other providers. Consequently, it may be difficult for PSMs, even those operating at scale with good track records, to compete as lead contractors for these roles.

So PSMs and other smaller providers may need to accept a different role in the overall picture, reflecting the fact that the lead contractors (whoever they are) are unlikely to want to deliver all of the services themselves – so will be looking for partners and sub-contractors. This may mean, for example, that smaller providers become sub-contractors to an acute trust running an ACO rather than contracting directly with a CCG or local authority. This may sound like a profound, in some cases uncomfortable, change.

So what can you do?

Whilst there is no room for complacency in this ‘brave new world’ there are steps you can take now to ensure you have a part to play under the new contracting arrangements:

  • Start participating today (if you haven’t already) in conversations with commissioners to shape ACSs and ACOs to be developed and contracts to be awarded.  Don’t miss the boat here, things do get forgotten.
  • Strengthen your businesses’ relationships with other providers, especially acutes / GPs, so you can be a key partner / member of the supply chain.

STPs and nascent ACSs/ACOs are setting up a range of governance groups to deliver their plans and it will be essential that smaller community-based providers are vocal in these groups (via a representative organisation even if not individually), as well as continuing to strengthen relationships on a more informal basis.

Assuming these providers can get over the initial challenge of getting round the table in the first place then it will be important to have clarity on what is expected from all parties and how this is set out.

In due course, once an ACO contract is awarded, there will need to be formal contracts with sub-contracts in place with all other suppliers including the smaller providers.   As we all know with contracts, this can take an age to appear.  In the meantime, providers may be encouraged to enter into alliance agreements of MOUs on a transitional basis. As with most documents, it will be the content rather than the label which is important when entering into these contracts.

Moving forward

In summary, to help maximise the chances of successfully safeguarding your organisation’s role in developing STPs, ACSs and ACOs, we recommend that you:

  • Get aware – by ensuring you are familiar with local plans for accountable care models put forward in your area through the STPs.
  • Get talking – by having early conversations with commissioners and other key providers to try to ensure that you have a seat round the table where plans are being discussed.
  • Get things documented- by ensuring that all parties are clear on their roles and responsibilities in developing accountable care models through alliance agreements or MOUs.

Let us know if we can of any help.

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