Ben Collins: Governance and accountability in new care models

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Ben Collins, Project Director at The King's Fund, discusses key questions for providers and commissioners.

This presentation was recorded at our conference on Governance and accountability in new care models on 8 February 2017.

Transcript

Transcript

My name is Ben Collins, I’m a project director at The King's Fund, I lead research on new care models and I lead some of the work that the fund does with NHS England and the vanguard sites, in particular the PACS and the acute care collaboration vanguards.

I have to say, I was a little bit worried when I saw the title of this conference and that I’d be leading it, Governance and Accountability as somebody said to me in the lift, that’s one step up from health and safety. I wondered how many people would come and I’m delighted to see a packed room, and we have people from all over the UK and even beyond, we have representatives I think in the room from the French Government.  So thank you everybody for coming, I think that reflects both the increasing seriousness in the UK about how we implement new care models and at a state that we’re currently in and the critical nature of the organisational underpinning and wiring of the systems we’re developing.

If you’ll permit me, I’d like to start off just by talking a little bit about a report that we did end of last year on emerging innovations in governance and the organisation form for the new care models.

So we now almost two years into the vanguards programme and acronyms have been breeding like rabbits. We have primary care medical homes, we have multi-speciality community providers, we have primary and acute care system and now on a slightly lower track I think, we have a set of chain and group models for hospitals.

I think this conference is really focussing on the first three of these models. Those attempting to fundamentally transform how a set of local health and care services are delivered so that they’re delivered in a more integrated and coherent way and make better use of resources.  I’d suggest that in our work at the fund with the PACS and the MCPs and other vanguards, we’ve seen a fundamental shift in language and focus over the last six months or so.

At the beginning of the vanguards programme the mantra was very much, this is not about organisational form, this is about the care models making changes on the ground, and increasingly I think the language has changed and we’re recognising that we really do now need to attend to the organisation infrastructure that’s going to underpin and support these new models. There’s only so far that we can go through collaboration on care hubs, the multidisciplinary teams, we can’t unleash the full power of these new models unless we sort out all of the institutional wiring as well; the budgets and the payment systems, where risk lies, the alliances and joint ventures of providers who are going to operate the new systems.

I’ve noticed an interesting change in language this year increasingly very large numbers of the PACS and the MCP vanguards are talking about developing accountable care organisations, accountable care partnerships, accountable pair systems. Now, accountable care organisation means different things for different people.  When you’ve seen on ACO you have seen one ACO, but I would suggest there are some broad common themes in what we mean, at least within the English system.  I think there’s broad agreement that in an ACO model commissioners will take a more strategic role, they’ll focus on the overall performance of the system rather than individual services.  There’s an agreement I think that lead providers or a partnership of providers will take responsibility for a capitated budget and a pretty broad range of health and possibly care services, broad enough to be held accountable for what they deliver for their populations in a way that’s not possible if you’re only responsible for a small part of the system.

I think there’s a recognition that providers need much greater flexibility to decide how they use resources, how they allocate funds, how they configure staff and other resources in the system to improve outcomes, and I think there’s a focus on longer term transformation.

So some common trends and a common direction of travel I think, at least for many of the PACS and the MCP vanguards. If that’s the direction of travel, I’d suggest there are four or five really key questions about system design, many of which I think we should try and keep uppermost in our minds for today.  The big question around scope, what budgets and what groups of services do commissioners want to bring together within the single long term contract?  Which provider or partnership of providers should hold that budget and be the main organisation responsible for overseeing the delivery system.   Really complex, but how will a really broad range of providers stitch themselves together into a coherent delivery system that’s capable of using these resources effectively.

And then what role should commissioners play in overseeing the system and how they’re going to monitor and motivate performance. So four or five key design questions, all of themselves worthy of a day’s discussion I think.

Just taking a few of these, a fundamental question for commissioners and indeed for provider groupings, is who is going to hold the capitated budget. The main choice appears to be between a GP alliance which was the main plan for most of the MCPs, a strong foundation trust which was often the plan for the primary and acute care vanguards, or a partnership between the two.  I guess key questions for commissioners are which of these organisations is going to have the authority and the credibility to determine priorities and allocate resources in the system.  Which of these organisations has the managerial and the technical skills to oversee the budget and add a complex supply chain?  Which of these organisations is capable post-uniting care of bearing substantial risk and coping with overspends in the short term?

So who holds the budget? And then once we’ve decided that, how are we going to stitch a very broad set of providers together into a coherent system, and I think in the NHS we’re getting increasingly used to seeing this as a spectrum of options, on the one hand you’ve got loose partnerships and subcontractor relationships, in the middle you’ve got different forms of more formal joint venture and on the end of the spectrum you’ve got consolidation of services through mergers.  There are some really tricky choices and I think that choice is for commissioners as much as the providers here as to how difficult it is to pursue some of these options, versus how stable the delivery system is going to be.

I mean it’s pretty clear to me that the looser partnerships are going to be a lot easier to put in place, they involve less formal pooling of sovereignty, they’ll be easier to stomach for many of the providers in the system, but how robust are those arrangements going to be when the finances really start to bite, when providers are thinking do we really want to participate in this or isn’t it more in our interest to walk away from this endeavour. So some tricky discussions to be had.

I mean we do paint this broad spectrum of options from loose partnerships to integration, but in practice these are incredibly complex system and like every other really complex industry, I image we’re going to see a lot of hybrid options developing. In practice, I would suggest that certainly amongst the PACS vanguards, you can see a common model developing, at least amongst some.  Commissioners establishing a really long terms strategic partnership with a lead provider or group of providers.  That lead provider holding the budget and playing the key role in coordinating services and overseeing system performance.

Alongside that lead provider, an alliance of really important public sector providers who need to work really flexibly with the lead provider and therefore need to be more of a strategic partnership than a contractual relationship and then you’ll have some subcontractors. Some who are really a market based relationship and just to take one quick example in Salford, commissioners hand the capitated budget to Salford Royal, Salford Royal has a close alliance with Greater Manchester West, the mental health trust, and then there are subcontractor relationships with some of the domiciliary and social care providers.

My hunch is that there will be a substantial element of integration in all of these models, in Salford for example there’s been a transfer of a large proportion of the Council Social Services into Salford Royal that now is responsible for acute hospital care, community services and adult social care. I’m not advocating a swathe of mergers but close integrations I think is probably a key part of these models in the longer term.

There are some really interesting and complex questions for commissioners regarding how they are going to oversee and motivate performance in these new systems. I think we can all understand theoretically and point a great example of bringing budgets together, of bringing providers into closer partnerships.  On the incentives, you know what we replace our current financial incentives with, I think that’s really uncertain.  I’d say we’d all agree at a high level on the need to move from short term input measures to longer term output measures, but there’s some real uncertainty about how that’s going to work in practice, you know how long will it take for us really to see what impact an integrated system has had on long term outcome measures and how will we know what contribution has the system made to those measures as opposed to all of the other things happening in a local community.

There are some difficult questions for commissioners about the use of financial incentives. Are soft incentives the best approach?  Benchmarking, will performance of our system against other systems allowing providers to retain savings or letting them cope with deficits or do we want much harder incentives?  Do we want to hold back money and pay it if certain targets are met?  And of course, does this happen within a profit making system or a not profit system.  I don’t think that academic research, economic thinking, examples from other parts of the world, really tell us the answer to those questions.  What I would say is that there’s an obvious trade off between the nature of the incentives and the complexity of the contracting arrangements that you’ll need to make them work, harder incentives are going to require a lot more skill and much more complex contracts that the softer schemes.

And then one quick final word from me on the role of competitive procurements and I think this is relevant, it’s certainly something close to my heart. Commissioners need to decide the process that they are going to use to allocate the budget and decide the lead provider and the delivery system responsible for delivering services, is very easy to articulate a range of arguments in favour of competitive procurements, but to get us to that point, you know, having a range of potential providers at the table, potentially revealing interesting delivery models, working out the appropriate price on the margin, identifying the appropriate balance of risk and reward, all of those wonder things that competition can deliver under particular circumstances.  Had I gather, there are also some real risks that we’ve seen in relation to uniting care, the recent Liverpool Community Services Contract and many others in relation to using very hard competitive processes to secure these new systems.  For one thing it’s going to disrupt existing partnerships, various problems occur as we saw in uniting care, reckless bidding, strategic behaviour, bargaining then ripping off once you’ve won the contract.  The transaction costs, potentially I think can spiral out of control.

So things to think about for commissioners and Robert can talk later about how you can dance through the current procurement rules if you wish to.

I guess one sort of very high level thing that we might want to keep in our heads throughout this discuss is, what’s the end point in all of this? Are we trying to develop a new care model, to put in place a new care model?  To roll out a new set of pathways of care for chronic diseases, appoint care coordinators, put in place multidisciplinary teams and care hubs?  I think that’s certainly an objective in the short term, but in the longer terms isn’t our aim to create learning systems?  To create systems capable of innovation and improvement in terms of how they use resources.  I’d argue that at the heart of all of these new models, PACS and MCPs, patient centred medical homes, the fundamental heart of these models is about the opportunities they create for improvement by breaking down traditional unhelpful barriers between primary care, community care, physical health, mental health, health and social care, they unleash a whole range of new opportunities that weren’t possible in the previous system.

They allow us to change the type of intervention and how resources are allocated in new ways, focussing on prevention rather than treatment, social support rather than prescribing pills. They allow us to change who does what in new ways, so, reconfiguring potentially the roles of GPs and community nurses in multidisciplinary teams.  They allow us to shift the locus of care, away from facilities to people homes and they allow us to improve coordination in new ways, sequencing interventions between primary, community and hospital services.  Managing the transitions, planning capacity across hospital care and social care.  So a set of really exciting new opportunities for improvement.

If that’s the objective, the long term objective, that has some interesting implications for a lot of the questions we’re thinking about today. You know, I can see us procuring a new diabetes pathway for a competitive tendering process.  I’m not sure how you competitively tender for an innovative learning system.  I can see us reconfiguring resources within broadly the current framework if the aim is just to put in place an MDT, we can change the doctors and the nurses contracts within their existing organisation so that they can work together in a new partnership, but if the objective is a learning system then we need a lot more flexibility in terms of how staff and resources are used.  All of that for me is pushing us towards much closer strategic partnerships or integration.

One last point, governance and accountability, it’s a little bit of a dry subject and there is a really important purpose in all of this. This is an example that I love, it’s breathe magic, it’s the spin off from the Guys & St Thomas’ charity. They offer courses for children with paraplegia.  So, paralysis on one side of the body in magic and they learn magic tricks and then they prepare performances and perform in front of their friends and their parents, and this is remarkable.  It produces impacts that could never be dreamt of for a traditional physiotherapy and it doesn’t just treat the body, it doesn’t just allow those children to do things they could never do before like, you know, opening a packet of crisps or tying their shoelaces or doing up the buttons on their coat, so life changing things, but they also create community, a sense of self-worth, really profound benefits, stuff that traditional health services couldn’t have delivered, and I think the key to all of this then is to understand that we have opportunities to see the problems we’re trying to address in very different ways and these changes, these arid changes to budgets and governance are the thing that will allow us to use our money better.

I’m going to leave it there and move straight onto Saffron and then we’ll take a few questions after Saffron.

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