'Let's stay together' - what are the factors that you think would help the nascent Accountable Care Systems to stay together and to work effectively and sustainably?

27 November 2017

Katie Lansdell, Associate Director

Why collaborate? The organisations that need to work together in Accountable Care Systems have subtly different (albeit overlapping) objectives and sometimes wildly different leadership teams – why would they want to stay together and put the effort needed into working effectively?

All about the patient? Having common aims and organising principles can help align those organisational objectives and focus the effort required to work together. One of the most effective ways we have found to bring this kind of focus is by putting the patient at the heart of what we do. But how much do we really know about “the patient”? Often, at the commissioner level, “the patient” is a set of metrics and measurable outcomes which amount to a set of needs. But we also know that those metrics cannot ever fully capture a group of people; their needs, desires and wishes. We need to be able to talk about real people in their real communities and have a shared understanding, throughout the ACS, of what that looks, sounds and feels like. We need to get better at knowing and expressing what the people we represent need and, most importantly, to have the confidence to have them in the room when we are making decisions about their services. If “the patient” is someone you really know rather than an abstract concept it’s much harder to ignore when things are going wrong.

Sustainability in an ever-changing world Common aims around a real understanding of who we are providing services for will help set the stage for working effectively together. But how to do that sustainably? What do we mean by sustainability in an organisational sense? An ecological definition of sustainability is that it is “a state of dynamic equilibrium, in which diversity remains stable but is subject to gradual change through natural succession”. That means that things don’t stay the same and change is inevitable – this is certainly the case for the NHS and care systems. The NHS we have today is not the same as when it was founded in 1948 and we shouldn’t expect it to be the same in 2048. Can the idea of natural succession be applied to health and care systems? Natural succession is where the make-up of a system changes over time, with pioneer species colonising an area in the beginning, some with the ability to subtly change the environment, allowing more sensitive species to follow. This idea of dynamic change is an important one and one that doesn’t feature much in current thinking – the organisations that form the nascent ACSs may not be the ones that see them through to a successful and sustainable future. Those organisations may be fit for purpose now, but they may also need to evolve into new forms, better able to meet the needs of “the patient”, as the relationships within the ACS mature.

Rachel Lewis, Analyst

“Knowing me, knowing you”: information and relationships in Accountable Care Systems

Accountable care systems (ACSs) were a hot topic long before Simon Stevens, Chief Executive of NHS England, announced the launch of eight ACSs in June 2017. Unlike similar arrangements in the US (often called accountable care organisations or ACOs), an ACS is a looser agreement between several healthcare organisations to take joint responsibility for outcomes. Given this, how can we ensure such systems stay together and work together?

What do ACSs and clownfish have in common?

At its best, an ACS creates symbiotic relationships. Integrated services provide patients with joined-up care while reducing unnecessary workload and costs across the system. Organisations should find that being part of an effective ACS benefits their staff as well as their patients.

Some healthcare alliances develop this further. The Montefiore ACO in New York, for example, attracts GPs with its hospital’s research prowess while integration with primary care has allowed the hospital to reinvest 60% of savings made. The reasons to stay together should be self-evident if the systems are working well.

So how can symbiosis be encouraged?

Evidence from existing ACOs indicates that three key factors are needed.

Strong leadership

Strong leadership is crucial to unifying a group of different organisations with different cultures and ways of working. Dr James Kingsland, President of the National Association of Primary Care, recently commented that ‘There is a feeling that if you say the words “transformation” or “integration” often enough then it will just happen.’ In PPL’s experience, leaders that see integration through make long term commitments to change and work hard to cement a shared vision of patient-centred care.

Aligned incentives

Aligned incentives come through governance and finance. Three often-cited healthcare systems - Ribera Salud in Spain, San Marino in Italy, and Kaiser Permanente in the US - all brought health and social care budgets together in some form. This can be done through capitated budgets (Kaiser Permanente) or extending the horizons of payment models (Ribera Salud). The goal is to make budgets flexible, enabling allocation to need within the system.

Mutual understanding

All the initiatives mentioned above have also benefitted from unified information systems. This does not only create a joined-up experience for patients and make it easier for a mental health nurse to collaborate with his new social worker colleague. Successful American ACOs use data to focus on high risk patients by stratifying their needs and tailoring interventions. This has been key to generating early savings and the NHS’s ACSs will need similar information, whether fully digital or not.

Knowing me, knowing you

Fundamentally, people stay together when they know they are stronger together than apart. For ACSs, leadership, aligned incentives and information sharing will be critical to making this a reality.

PPL believe that integration is an opportunity for the NHS to become still more than the sum of its parts to meet growing challenges. We hope that integration will work out better in the NHS than it did for ABBA and that this year’s nascent ACSs will stay together for decades to come.

Claire & Simon, PPL Co-founders

Working in partnership - with each other, with colleagues, with clients and with those they serve – is fundamental to what we do.  We know how difficult it can be.  But we have also learnt that unless we succeed at this, we are unlikely to succeed at anything else.

Our needs change over time, as do our public services and the money available to fund them.  What remains the same is that no single service can meet all the needs of individuals or communities.  As those needs increase and funding pressures grow, public sector organisations have to work together like never before if we are to achieve better outcomes. Intellectually, most people agree that collaboration between services has to improve.  Practically, what most people continue to experience and articulate are the barriers to achieving this. 

There are many, many reasons given for why partnership working fails – from organisational structures and differing financial and regulatory structures, to history and culture - the list goes on.  But in some areas, it is starting to work.  In these areas collaboration is becoming part of the fabric of service provision, and as a result the system has started to bend itself into a shape that fits around the service user and, therefore, to look quite different. What is different about those areas, and what can we learn from them - both about how other areas can achieve similar results, and why overall it has proven so hard to achieve these at scale?

One thing that is not different is the statutory and budgetary context – there is no silver bullet to deal with the web of regulation and complex structural relationships between organisations. Budgets and responsibilities remain split, savings flow ineffectively around the system, accountability is diffuse and often difficult to identify – these areas do not get an easier ride than anyone else. So why do some areas make progress towards integration when others struggle even to get people into the same room to have an initial conversation? The clue is in the question – it’s about the people and the relationships. In these areas, the thing that is different is the behaviours. 

Areas where genuine collaboration is underway tend to tell a very similar story and it is, above all, a human story about people trying to create something different by behaving differently.  People cite the ‘relationships’, ‘bottom-up collaboration’, ‘getting to know each other’, ‘co-location’ and ‘conversations’ as some of the things that have made their collaborations work.

The common theme is that these are all elements of practice that talk about ‘how’ you do things, not ‘what you do’.

Whatever we think about what the national bodies can do to help integration (and we are not saying that greater pragmatism and perspective around regulation wouldn’t be welcome), if we start to see the main, critical factor in integration as individual behaviours and, by extension, the human choices that motivate those behaviours, it is not hard to see why the solution to the current slow progress cannot come from central directives alone.

Organisations and professions are human creations; changing the way they operate means changing the way people behave. But we also know that changing behaviours is the hardest shift of all – far easier to reorganise, outsource, insource than ask people to do something differently for no reason other than that what they have been doing previously could be done better if they did so.  What we see is that there are leaders at all levels within organisations who can take their teams, colleagues and organisations on this journey. But what we also recognise is that these leaders are not “better” than other people. What they do works because they share an understanding that collaboration is a human process, with different rules of engagement from the task-led model of traditional service delivery. They find ways to reach those around them, enabling them to feel connected to each other and to the outcomes they are trying to achieve, not to the comfort blankets of custom, practice and fixed identity.

We know this is no easy task - experience demonstrates that true connection is one of the hardest things for any of us, as human beings, to achieve, but so critical in enabling us to work differently.