Survindar Chahal FPM Content Manager

Accountable Care Organisations - A New Care Solution for the NHS?

ACOs have been identified in some areas as the future of the NHS – but just what are they and do they really represent the direction in which the healthcare system is heading? Also known as an Accountable Care System (ACS), they have been mentioned in conversations at commissioning level and above for some time now and are seen as an ideal way to bring multiple provider organisations into a single, coherent group.

An Accountable Care Organisation (ACO) is an American organisational model which grants joint responsibility to a range of healthcare providers for the budget and quality of care delivered in their designated regions.  Some are structured and integrated care systems, while others are informal associations between primary, urgent and secondary care providers.

How Do They Work?

Basically, they involve giving a budget (based on local population needs) to one or more organisations with the fixed objective of delivering specific outcomes for that population’s health needs. Incentives are inevitably involved, with priorities including keeping people as healthy as possible (so they reduce the need for using health services), and minimising the need for hospital-based care provisions by having more community-based services available to patients.

This means more emphasis on preventative care, delivered by a combined team of GP practice care, nurses and pharmacists – anything from monitoring high-risk patients to directing them to other non-hospital care.

There are different systems of ACOs in the US, some of which are GP-led and similar to the super-practices that have sprung up recently. Alternatives include joint provisions between primary and acute-care providers, or hospitals working with practices, walk-in centres and nursing care homes.

Together, ACOs will serve a local population and be held accountable for the improvement of its health, as well as any associated budgets. Interestingly though, financial accountability varies within the US - several ACOs were made accountable for the financial losses as well as gains, while others could share the savings made with the funder, but did not have to bear any of the losses.

ACOs and the Commissioning Process

ACOs see groups of providers ‘partner up’ and take responsibility for all the healthcare needs of a given population for a contracted period of time, as agreed with a commissioner. Already there have been many CCGs considering or researching the benefits of ACOs, and some of the ‘Vanguard’ sites are trialling the approach. If you’ve heard the term “place-based care”, that’s what ACOs are meant to achieve – it’s a more ‘NHS-friendly’ term that was used liberally in the recent Five-Year and GP Forward View documents.

The key thing here is that ACOs will be ‘hands-on’ – they deliver care, they don’t commission it. By taking control of the delivery of patients’ care, they can deliver solutions that will hopefully reduce the need for hospital visits – this could mean more services being offered by GP practices, more community-based providers, or something else entirely.

From a commissioning point of view, if ACOs form part of the new Sustainability & Transformation Plans, it might mean they come onto the field of play as either an alternative or partner to CCGs, but either way space will need to be made for them – reducing the number of CCGs could be a real possibility, as could replacing them with regional financial controllers/commissioners that will monitor the performance of ACOs against their contracts. An example of a recent publication on ACOs in England can be found here.

Can They Work In the NHS?

ACOs have had mixed results in the US – they were introduced as part of the Affordable Care Act in 2010 (better known as Obamacare) and in those six years some have reported hitting quality targets  and reducing hospital admissions,  while other have suffered financial losses.

A logical and balanced approach seems to be what’s needed to make it work – essentially, it could be the perfect vehicle for the idea presented in the Five-Year Forward View of a community-based, holistic approach to providing all of the health requirements a patient needs. It needs to be managed properly however, taking into consideration issues such as region-specific health, deprivation, budgets and - most importantly - the ability for the relevant health providers to work together effectively.

We’re already seeing CCGs struggle to balance the books (most CCGs started out day one in the red), so if ACOs are to come into our systems, there needs to be some careful consideration about how and where they fit in and what work will be needed to make them work and deliver on their promises. The conclusions from the US-based ACOs identified the need for ensuring they don’t get too bogged down in complexity – one network held four ACO contracts, which meant they were having to hit a total of 219 performance and quality targets.

Consideration will also have to be given the involvement and engagement of patients. If part of the role of ACOs is to reduce hospital admissions, then they’ll need to be actively speaking to patients about how the process works, as well as involving them in how their care will be delivered and decided, especially long-term and end-of-life patients. Much of this is in the Five Year Forward View, so it is likely that it will be an objective/incentive for ACOs to get patient input and involvement in this redesign of care.

It’s important to remember that although Jeremy Hunt and NHSE have been lauding the success of ACOs in the US, they are still new systems and are effectively finding their feet. Lessons are still being learned from what is essentially an experiment in American healthcare – some things have worked, some haven’t, and we shouldn’t be in a position where we try to shoehorn the best bits into our own NHS. Any ACO or ‘place-based care’ model has to have the ability to manage their own budgets and services, work with others and set up its own ‘provider network’ that delivers results for patients.

Lessons Learned from the US Models

• Focus on the small proportion of patients who account for the most use of healthcare services and tailor a care package for them
Target the high-risk patients that have the greatest need (or the highest use) of NHS services
• Use case management and care co-ordination programmes for high-demand patients
Support high-risk groups with a case management system to monitor, assess, plan and co-ordinate their care
• Develop information-sharing processes
Access to clinical information needs to be available to all clinicians – we already have access to health analytics and an IT development strategy intent on data sharing to facilitate this
• Engage and involve patients to enable them to manage their own health needs 
People with long-term conditions or care needs should be involved in planning their own care with healthcare professionals

Could ACOs be the future of the NHS? What do you see as the pros and cons of this approach? Let us know in the comments section below, and stay tuned to the FPM Blog to learn more about the latest developments and news stories relating to primary care.

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