Paul Maubach: Planning to use the ACO contract

This content relates to the following topics:

Article information

  • Posted:Wednesday 21 March 2018

Speaking at our breakfast event on Integrated care on 21 March 2018, Paul Maubach, Chief Executive, Dudley Clinical Commissioning Group, explains why his organisation intends to use the controversial Accountable Care Organisation contract.


  • PM: Paul Maubach
  • CH: Chris Ham

PM:    There is one thing that we can agree on which is that we want better integrated care.  In fact, I struggle to find anyone that argues that we want disintegrated care.

    There’s a key reason for that.  And that is that the demand and the need from our population is changing.  So, if you take Dudley, a third of our population now are living with at least one long term condition and they want really effective continuity of care of the different professions that link to delivering and supporting their long-term condition to work better together.

    And we also have more and more people living with multiple complex capabilities and they don’t just want good continuity of care, they want really effective co-ordination of care as well.

    But, in addition to that, if we’re really going to deliver sustainable services we need our population to be able to take better self-agency for themselves, with themselves and their carers and their social networks and we need to be able to support that better, we need to be able to take a longer-term population health management point of view.  That is why we need better integrated care because we need to better design the way we’re delivering services around the person.  You can’t achieve better continuity and co-ordination or better long-term population management unless you design services around the person and the population.  And that’s why we want to deliver better integrated care.

    In Dudley we’ve already had a partnership in place for quite a long time which has involved the CCG, the council, our NHS providers, the voluntary sector and others to work together to deliver some of the improvements that we’re trying to achieve on continuity of care and effective co-ordination.  So, we’ve had multi-disciplinary teams in place for many years; teams of staff from across the different agencies working together around general practice to deliver better co-ordinated care for our population.

    And the results that they’re delivering are staggering.  The patients that they are seeing, two-thirds of them now report that they feel much less socially isolated than they were before because they’re getting a holistic service.  They feel much more confident in the management of their condition so that their use of primary care has reduced by as much as 24%.

    So, we’re already delivering better outcomes and better care for our population.  You might think that’s an argument for saying well, let’s leave things as they are, let’s leave them as an alliance partnership.  Why do we need to go the step further?

    And my argument, quite simply, is if integrated care is the right thing to do, why wouldn’t you want to do it to its maximum potential benefit, to deliver the maximum benefit you can for both our population, but also our staff that are trying to work with our population.  Why wouldn’t you want to try and maximise their potential to work effectively together in the best interests of the population they serve?

    And there are really kind of four fundamental reasons, I think, why, for us, trying to achieve that maximum potential integration through a single integrated care organisation which, for us, is the MCP supported by a single population-based outcome-based contract is really important.  And there are four reasons.
    First of all, it’s about outcomes and it’s about outcomes for the population and for the patient.  And those outcome improvements are multi-factoral.  We’ve done a lot of work in Dudley trying to look at what are the outcome of benefits that we want to achieve and how do we bring staff together to most effectively achieve those outcomes.  But you’re only really going to be able to maximise the potential on that if you can genuinely integrate systems, integrate ways of working, because it is a really complex challenge and a complex task.

    But the outcomes work and the objectives that we’ve set in Dudley, we think that the impact of that if we do it successfully over the first 5 years of MCP being in place, is that we’re aiming to improve healthy life expectancy by a year and a half for the population as a whole.  So, in 5 years the average healthy life expectancy will increase over and above current trends by a year and a half.

And we can already evidence that by some of the work that we’ve done so far.  So, for example, in hypertension, standardised mortality and hypertension in Dudley with a concerted effort year after year, teams working together across primary care with our practice-based pharmacists and others, we’ve reduced standardised mortality in Dudley from more than double the national average to 20% below the national average.  We’ve done that because we’ve integrated the way we’re working.  And we think we can deliver more and deliver better outcomes for our population if we integrate to the maximum potential.

    The second key reason for trying to establish a MCP or an integrated care organisation is all about primary care, our GPs.  If you talk to the public, which we’ve done a lot of in Dudley, we’ve done a lot of engagement and consultation on this, for them the heart of the NHS starts with the general practice and their registration with a GP.  In Dudley, if you take account of closures of branch surgeries, we’re losing a practice once every six months at the moment, and that’s because primary care in it’s current form is not sustainable.

But general practice and our GPs are central to the way we deliver care and they are essential to the way the public expect care to be delivered.  They are at the heart of the NHS.  So, we need to find ways of making primary care more sustainable.  And for us, that means GPs leading multi-disciplinary integrated teams, being supported by a much wider network of services around general practice.  Not having general practice standing alone.

    The ACO contract and the MCP offers the opportunity to integrate general practice with the rest of the NHS in a way that’s not been done before.  It doesn’t enforce it, but what it does mean is that you can’t create an ACO, you can’t create an integrated care organisation without general practice, because general practice is at the heart of the system, and it’s the heart of the organisation.

    And there are two ways in which our GPs can be involved; either being what’s called partially integrated, where they have a formal integration agreement about how they collaborate for mutual benefit between the practice and the rest of the system.  Or they can be fully integrated along with the rest of the staff in the integrated care organisation.

    But the point about it is that it’s flexible, but it also places general practice at the heart of it and you can’t deliver it without general practice support.

    The third key reason is benefits to our wider staff.  So, the strongest advocates for our integrated working in Dudley are actually the staff who are in our multi-disciplinary teams.  If they were up here on the stage they’d make a much more eloquent job of describing the benefits that they have, that they experience with their patients and that they experience together, because by being able to work together as teams they’re identity and purpose as a team together, with the patients they are working with, is much stronger and much more purposeful and much more meaningful than necessarily the individual organisations that they’re all part of.

    But one of the challenges that we have at the moment is that whilst we have fully integrated teams at the interface with the patient and with the population, they’re all part of separate organisations and they’re all reporting in through managers to chief execs to boards that are all separate, that all have separate accountabilities, that all work to separate objectives set by the regulators, that actually work for separate objectives set by us as a CCG.  Far better if we have one single management, one single board that’s aligned to the purposes of our frontline staff, that’s aligned to the purposes of our patients to deliver that integrated care.

    We think we can achieve far more progress far more quickly if we have a single organisation that’s, not a top down approach, but is behind our staff enabling them to maximise their potential with our population.  And also, by having genuinely integrated teams we think it offers far more opportunity for workforce development across the different professions because they’re all working as one for one organisation.

The last reason for creating accountable care organisation is from a commissioning perspective, so I’m a commissioner of services and at the moment the way we work commission healthcare actually works against integration.  It’s a complete nonsense that we commission healthcare that works against the way our patients and our population and our staff want to work.  And I’ll give you one simple example, but there are many, if you take diabetic care; in Dudley there are about 20,000 diabetics all of whom are seen by their GP, all of whom their GP is working to an outcomes framework which is about supporting the stable management of those patients.

A significant number of those patients also see the diabetologist based in the hospital, but we don’t pay them on the basis of supporting integrated working.  We don’t pay them on the basis of supporting better long-term conditions, management of their patients’ condition.  We pay them regardless of the outcome they achieve, on the basis of the more times they see someone the more money they get.  That’s a nonsense.

    Why aren’t we aligning the way we commission care to support our diabetologists and our GPs to work together to the same outcome objectives?  Why aren’t we paying for social workers, our mental health workers, our community staff to work together collaboratively on MTDs with our GPs?

    So, it seems to me, that we have a duty as commissioners of healthcare to align the way we commission to the way our public and our patients and our staff want to work.  To actually go against that is, quite frankly, irresponsible.  We have a duty to do what we can to commission services in a way that maximise the potential for our staff to work effectively with our population.

    To kind of summarise; for me the key question is; if you agree that integrated care is the way we should be delivering services, then how far do you want to go with this?  We can leave things where we work in partnerships and alliances and we can make a lot of progress on that, and we are making a lot of progress in Dudley on that basis.

But personally, I think we can go a lot further and deliver much better results and achieve much more if we genuinely fully integrate the way we deliver services.  That way we maximise the potential for our patients and our population and we maximise the potential for our staff to achieve what they can for their population.

    Thank you.

CH:    You have identified 2 local NHS trusts as the preferred provider of your ACO?

PM:    Yes, that’s right, yes.  And they are coming together actually to create a new NHS trust which will be the integrated care organisation.