Rachael Addicott: Governance for new care models

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  • Posted:Tuesday 07 June 2016

Rachael Addicott discusses The King's Fund's research into governance for new care models.

This presentation was recorded at our event on Multi-specialty community providers and primary and acute care systems on 7 June 2016.


I'm going to talk to you a bit about some of the research and work that we’re doing at the moment and what I'm hoping to do is set the scene for what Jackie’s going to talk about and some of the things that you might be thinking about both for the rest of the day and when you go back to your organisations and systems after today as well.

When we think about governance in the work that we’re doing at the moment, I think about it in three different ways rightly or wrongly, but this is how I think about and some of the work that we’re doing. So I think about governance in terms of the organisational structure, whether it is accountable care organisation, whatever it is you call it, however it’s structured, legally formed etc. I then think about how the governance works within that, so what are the ways that decisions are made, and what are the groups that make those decisions, what are the flows and sign-offs that need to happen within that system that you called yourselves and legally developed?

And then there’s the process of governance, how I think about it, and this is more the accountability side. So how all of those partners work together on a day to day basis, and this is the framework for the work that we’re doing at the moment. It is very early days, you’ll notice that most of my doc points have question marks at the end of them rather that full stops or anything definitive but it is just to get you thinking about some of these issues.

What we’re doing at the moment is trying to get a bit of a baseline of what the vanguards PACS and MCPs in particular are thinking about some of these issues around governance, what are the aspirations, what are the early plans, what are the challenges that you see in the way of what those plans actually are? And I’ve probably badgered quite a lot of you in the audience to speak to me over the past few weeks and over the coming the month to try and get under the skin of what some of those plans and what some of those challenges are.

This is the starting point, I suppose, from the work that we’re doing at the moment, and this was a report that we published about 18 months ago, which was primarily looking at what CCGs were doing to encourage more integrated working, what levers CCGs had available to them and this pre-dated the five year forward view. And this very much focused on contracting mechanisms. But the lessons that came out of that are on the screen here and it’s the fourth of those that spurred what we’re doing at the moment. And what we saw was that there was a lot of attention on the contract, the organisational model, that first aspect of governance that I was talking about. But very little attention being paid to what was going to happen once that contract was signed, once the ink is dry what is now a vanguard, a new care model, an integrated partnership of any kind of form, how that actually operates on a day to day basis, how managers risk and relationships and accountabilities etc. So that’s been the starting point for the more recent work that we’re doing.

And these are some of the questions that we’re asking vanguards as we’re going out and talking to them. And it’s worth pointing out that it’s not about necessarily an evaluation of the vanguards, what they are and aren’t able to achieve, what standard they’ve got to but this is a useful cohort for us to start to understand some of these governance issues around legal arrangements, financial arrangements, what are the rules around entry and exit, how does it operate on a day to day basis, how do you hold yourselves to account and then how does the wider environment support some of those arrangements as well?

And we can already draw on some of the lessons from accountable care organisations and what’s happening in the States. I had the fortune of spending about 18 months in the US working with ACOs around some of these governance and accountability issues. And we might not call ourselves an ACO, some of the technicalities of it might not work in this context, but there are a number of principles within the ACO world that resonate for what we’re trying to do here and it’s about coordination of care, thinking about population level, governance, accountability and sharing risk and some of those savings as well.

And in the work that I did there I was asking the ACOs and talking to them a lot about what are those processes of governance and processes of accountability that bind you all together? What are the levers that you had available to you to move outside of those organisational silos and operate more collectively? And what we came up with was a framework from what I call a softer, more peer influence, wanting to work together, appeals to professional competitiveness etc. right down to a hard end which is about removal and exit from an ACO, or exit from an integrated care model. And we could see all of these different levers actually happening in practice.

So when thinking about our work now it’s about how do any or all of those levers apply within the NHS context? Are they acceptable, are they palatable, would we accept removal of partners from a vanguard or from another kind of inter-organisational partnership? Do we have enough data and information that’s transparent that’s comparable to be able to make some of these decisions and use that information as a lever? Some of the financial incentives that ACOs are using as well shared savings, what works, what’s acceptable, shared savings, shared risk, bonuses, penalties etc. and then really understanding that risk that you’re all taking on as well.

And again we heard this morning, and one of the things that clearly came out of the ACOs was about the ingredients for success, how you actually operate in this way and what needs to be in place and what the ACOs were very very clear about was that data, comparative information, IT systems that are joined up in order to understand risk that you’re taking on, in order to understand achieving those quality outcomes etc. is absolutely fundamental. And then also agreeing those clear attributable negotiated metrics as well.

So just some final thoughts on that. Essentially when we’re looking at governance and some of the things that are really taking people’s attention at the moment, it is about managing risk, agreeing those outcomes, making sure that they are attributable, manageable and challenging and measurable as well. Really focusing on information technology and this has come up this morning and at other times as well, but what is the information that you need to be able to manage that risk, understand the risk that you’re taking on collectively? And also what keeps everybody at the table when it gets hard? There’s a lot of pressure I'm hearing when I'm going out and talking to vanguards at the moment in trying to balance what the vanguard’s trying to achieve against the pressures that are facing individual providers against the deadlines and aspirations of the STP arrangements as well, so if you’re operating within a vanguard what is keeping you all at the table focusing on those collective measures, focusing on developing those information systems and ways of working etc.

What we can also learn from some very clear examples in the US as well is that if the organisational entity doesn’t have the capabilities and skills to manage care in this way, to manage and understand that risk, manage contracts etc. it’s going to be extremely challenging and we’ve seen a number of programmes in the US fail because they don’t have the capabilities to work in this way, they don’t have the sophisticated information, they don’t have the ability to manage a cheque book on behalf of a whole system.

And one of the other things that’s happening in the US and that I see perhaps as a slight warning here is about managing conflict. And what we saw in the previous work around contracting for integrated care was that there was quite an extreme optimism bias I would suggest where organisations and partnerships that are bidding for work or developing business cases etc., are very optimistic about what they’re able to achieve and by when and within what cost envelop, but very little attention paid to what happens if things go wrong? What happens if things don’t go as we want them to? What happens if organisational pressures take over? What are those entry and exit rules? And the time to be focusing on those areas of conflict and the what happens if, is not when you get into the situation of it happening, but when things are going well, when everybody is around the table and trying to avoid being overly optimistic about what’s achievable but instead being realistic about that.

And the final point that I want to leave you with, and this came up in the previous session as well, is I suppose contradicting everything that I’ve just said is that this isn’t just a transactional relationship, it’s not just a contract, if you have to rely on a contract or an organisational structure or a flow chart in order to get partners at the table and get everybody working together, you’re starting from a pretty I suppose unstable platform, what we learned from the previous work with contracting and what we can learn from the experiences of the more successful ACOs and what I'm hearing going out and talking to vanguards now is that this isn’t getting everybody at the table for the first time to think about how a contract or an organisational structure can bind you all together, these are longstanding relationships. You wouldn’t enter into a marriage contact without developing that relationship first, if you have to rely on that marriage contract to be nice to each other on a day to day basis, then there’s something going pretty wrong there. It’s about developing that trust and those productive relationships and essentially that keeping you at the table when things get hard in practice.

I’ll leave you there.


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