Chris Ham: Accountable care organisations in England

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  • Posted:Tuesday 11 October 2016

Chris Ham talks about the challenges and opportunities posed in the establishment of accountable care organisations (ACOs) in England.

This presentation was recorded at our Integrated Care Summit on 11 October 2016.


What I would say, having you know, spent some time pre ACOs, visiting and learning from the integrated delivery systems like Kaiser Permanente and Group Health and Geisinger and many others besides in the States, is that you’ve seen one ACO, you’ve seen one ACO. But if you look across the family of ACOs, what you see is some common and important ingredients and they’re the ones I have listed on this slide here.

When you look under the bonnet of ACO you see these kinds of things, and this is not new to us, is it? We’ve been working on these issues at least for ten years and probably longer since there was a growing understanding about the shifting burden of disease, the increasing importance of chronic conditions, the issues around age in populations and frailty, and where are the biggest opportunities? Well, understanding the population being served and stratifying by risk.  Using case management to support people with complex needs.  Improving flow in hospitals, by using hospital lists and discharge planners, increasing the news and of course, following up post discharge to maintain contact with patients and to ensure they are in good health in their own homes.  Not forgetting expert patients, supporting people around self-management and indeed shared decision making.

If you want to try and save the eye watering sums of money that the NHS in England is required to save, you’ve got to understand where the money is and we’ve got to focus on acute hospitals in the NHS because that’s where the money is. An opportunity may be through some of these mechanisms to shift care delivery out of acute hospitals into alternative settings by doing these things systematically but this is the sociological bit, the hard bit.   How can we do that in England?  We have a system that fundamentally was setting up the legislation to promote competition between organisations, as sovereign bodies and we’re now asking leaders to forget some of that and be good corporate citizens and to collaborate in the development of ACO type models of care.

Using a non-US example, and some of your will have heard the story of the Canterbury Health Board before, I think it’s a very powerful story and a very different jurisdiction, much more similar to England than the United States. Their vision of Canterbury having one system, one budget, I think has a powerful set of evidence about what can and should be done to move from organisations to systems, from SILO budgets to one budget and to get the collaboration alliances, as they talk about in Canterbury, on which their success in integrating health and social care is based.

It’s just a huge amount of effort going into thinking about the governance and the organisational form in the ACOs that we see emerging through the Vanguard programme. That’s understandable, it’s necessary, it’s important but if you simply put in place new governance and new organisations without a strong underpinning around the relationships between the organisations and their leaders and their clinicians involved in these provider partnerships, frankly you are setting yourself up to fail.

So, talk to the lawyers but also think about how you can move beyond competitive behaviours, the collaborative behaviours, from organisational leadership to system leadership.

And this is a slide I borrowed from Michael West, one of our colleagues here. Michael’s a psychologist by training and he says there are five golden rules if you want to build collaborative relationships and these are they.  You’ve got to have frequent personal contact with the people you want to collaborate with.  Going to a partnership board once a month or even worse, once a quarter, and expecting that to develop into collaborative system relationships is a route to disaster.  It’s about being in it for the long term.  This is about how you collectively, in your county, your borough, your city, plan to work for the next five, ten, fifteen years, based on a shared purpose and shared vision.

It’s about being able to surface and resolve conflicts because there will not always be agreements, there will often be legitimate differences about how the money is used and how you deal with say, overspending in acute hospitals when you’re trying to achieve parity of esteem for mental health or investing in under-invested primary care services, and it’s moving beyond self-interested behaviour which a competitive market assumes, to behaving altruistically.

So the conversation is about how can I help you in the mental health trust or in primary care, deliver on your priorities and how can we work together, not how can I simply adopt the fortress mentality and look after my organisation’s budget and its performance.

So the key message from me really is about marrying this emphasis on relationships and cultures and collaboration with an understandable focus on governance and structures and organisation form which is a strong message from the report we published today.


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