Accountable care: policy fad or step forward on the journey towards integrated care?

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Accountable care is under discussion almost everywhere in the NHS. Groups of NHS providers (sometimes with the local commissioner) are exploring how they can work more closely together to take on the responsibility for the health and care of a given population within a given budget. Currently, we are seeing emerging accountable care arrangements adopting various forms according to local needs and preferences: in some areas the focus is on creating a single organisation; in others, organisations are keen to use the words ‘system’ or ‘partnership’ – to reinforce the notion of working together.

Frequently, accountable care systems (ACSs) and partnerships are either all organisations within a single sustainability and transformation partnership (STP) footprint or groups of organisations within an STP that have chosen to take on collective responsibility for the health of a population within a set budget in exchange for greater autonomy. The size and structure of these ACSs and accountable care partnerships (ACPs) varies. In one STP the Fund is working with eight organisations – one clinical commissioning group (CCG), three acute providers, a combined community and mental health service provider and three local authorities – to create a single ACS covering a population of 800,000. In another STP covering a population of 1.4 million, there are 11 organisations – two CCGs, three local authorities, four acute providers, a community services provider and an NHS mental health trust – working together to develop four ACPs.       

Bringing individual NHS organisations together to achieve collective targets and goals in addition to their individual organisational targets is challenging, especially without any supportive legislation. In many places leaders are using the absence of centrally defined structures and processes to determine what they need locally. In some places regulatory bodies are supporting system-wide working but this is not always the case.  

In some areas, leaders and managers involved in developing these new arrangements are simultaneously addressing structural issues – such as aligning organisational goals, engaging staff, and developing new contracts and governance arrangements – and ‘softer’ but equally important issues such as developing shared cultural values. In other areas they are working on ‘real issues’ but in new ways, to begin to build trust between (in some cases) previously competing organisations. 

In one recent learning network meeting at the Fund we explored different organisational development approaches to change, and participants spent time carefully designing how they may ‘intervene’ to shift the nature of the conversations they are holding locally. By attending to both the hard/technical issues as well as the soft/relational issues I would argue there is a real opportunity to use the development of accountable care organisations (ACOs), ACSs and ACPs to move beyond ‘more of the same’ incremental change to secure the transformational change needed to make integrated care for patients and carers a reality.  

Evidence from ACOs in the United States is mixed but there are other places such as Canterbury District Health Board in New Zealand where they have successfully created a single health and care system with strong GP and primary care engagement. By working together as a single system with the central belief of ‘one system, one budget’ they have moderated demand for hospital care. This has taken time and investment in community-based services to support people to take more responsibility for their own health and wellbeing, and as far as possible to stay well in their own homes and community. 

Whatever acronym we use to describe it, the process of developing accountable care arrangements is far from simple. But the evidence from areas such as Canterbury show that the prize of more integrated health and care is one worth striving towards. 


Gay Lee

Not representing an organisation - my personal view
Comment date
16 October 2017
I think the key words used in the blog are 'time and investment' in relation to the relative success of the Canterbury, NZ system. The Kings Fund itself has shown that there is no evidence that these kinds of schemes (whatever one's views of them) work within tight deadlines and declining budgets. This is precisely the situation we are in in the UK. It seems that there is a mass state of denial about this and a lack of effective protest about the futility of trying to create such massive change in the face of a lack of evidence that it will work.

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