Commissioners and providers in Northumberland have a long history of partnership working. For example, the county council and the then health authority pooled some budgets, created integrated teams and worked on joint strategies for community services in the 1990s. A care trust was set up in 2002, with most of the council’s adult social care functions delegated to it. Since 2011 operational functions have been delegated to Northumbria Foundation Trust, while the council and the CCG have worked closely together as commissioners, with arrangements including delegation of NHS Continuing Health Care commissioning to the council.
The two commissioners started working with Northumbria Healthcare and other partners to develop these arrangements with the aim of establishing an accountable care organisation that would oversee the full range of health and care services for adults. The initial objectives were to address current deficits and ensure financial sustainability, with medium-term objectives around reconfiguring services and moving care out of hospitals. Longer-term objectives were to deliver improvements in population health outcomes.
System leaders explained that they were pursuing a number of key phases in establishing the model. The first was to reconfigure hospital services, in particular through opening a new emergency care hospital and separating the delivery of urgent and elective care on different sites; the second was to consolidate primary care and develop primary and community services to provide care out of hospital; the third and final phase was to make the necessary changes to budgets, incentives and the provider system necessary to operate an accountable care organisation.
Under the new arrangements, the CCG will transfer its funding for most core NHS services to an accountable care organisation, which will operate as a partnership between Northumbria Foundation Trust; Northumberland, Tyne and Wear NHS Foundation Trust; the mental health provider, and other providers. Northumbria Foundation Trust will hold the formal contract, but it will be managed through a type of partnership arrangement with the other providers. The delegation of the council’s operational adult social care functions to Northumbria Foundation Trust will continue.
The accountable care organisation will make all ‘tactical’ decisions about the deployment of health resources, effectively taking over many of the detailed tasks currently carried out by the CCG. A ‘strategic’ commissioning function will remain outside the accountable care organisation. This will be supported by a joint strategic commissioning unit hosted by the council and reporting to the statutory CCG board on NHS commissioning and to the council on social care commissioning. Funding for partnership arrangements between the CCG and the council, such as the integrated commissioning of Continuing Health Care commissioning, is expected to remain outside the contract for the accountable care organisation.
Northumbria Healthcare and the other providers will establish a board to oversee the accountable care organisation. As a condition for joining, providers will need to agree to the move to capitation and to work together to move care into the community. They will also need to agree how to share funds, including any savings or overspends.
Alongside these changes, local leaders are pursuing strategies to consolidate primary care so that it can play a stronger role. Primary care leaders in the county are debating which of five organisational form options could most effectively serve to support their role in the accountable care organisation from April 2017 and will conclude these deliberations later this year.
The intention is to bring these groupings together as a single entity to participate on the accountable care organisation board. The main motivation for GPs is to be able to influence strategic direction. There are no immediate plans to include core primary care in the accountable care organisation’s pooled budget.
Commissioners envisage that the health and wellbeing board will continue to oversee the overall priorities and outcomes of health and social care commissioning. The CCG board will continue to oversee and make final decisions on the contract with the accountable care organisation and to monitor system performance.
Commissioners are in the process of developing an outcomes framework as a basis for monitoring and incentivising performance within the new system (rather than using financial incentives).
Finally, commissioners plan to establish a small joint commissioning unit within the council to make best use of commissioning resources, while transferring tasks such as contracting with and overseeing individual services to Northumbria Healthcare.