interviews

25.07.17

Enabling greater integration through ACSs

Source: NHE Jul/Aug 2017

At this year’s NHS Confed, Simon Stevens revealed the first wave of accountable care systems (ACSs). NHE speaks to Ian Dodge, the director responsible for NHS England’s strategy and policy, about the developments and direction of travel.

Shortly before the general election was called, which seems somewhat in the dim and distant past, NHS England launched its ‘Next Steps on the NHS Five Year Forward View (FYFV)’ document. It outlined a number of key policy areas and gave the sector an update on STPs and the move towards more ‘evolved’ ACSs. 

The document, once again, reiterated the direction of travel in that across England, “commissioners and providers across the NHS and local government need to work closely together – to improve the health and wellbeing of their local population and make best use of available funding”. 

Speaking to NHE following the general election, and after Simon Stevens unveiled the first wave of ACSs, Ian Dodge, the director responsible for NHS England’s strategy and policy, said that “when money is increasingly tight, there is something about how systems come together more effectively to work through some of the difficult decisions collectively – rather than lots and lots of energy being spent battling against each other in a battle of the spreadsheets”. 

Stefan Rousseau - PA Wire edit

Discussing the FYFV update document, Dodge added that NHS England wants to enable new and more integrated forms of provision to emerge, but there is still work to do. 

“If you look at our health system compared to a number of other international systems, then the boundary between what providers do and what commissioners do could move a little bit more in line with those international models,” he said. 

“If you look at what has been done with things like the New Care Models programme, it is absolutely working on that bit of provider development, and how the different services come together to deliver the best place-based services in local populations while dealing with the challenges of rising demand, adopting new technologies and making the best use of the workforce.”

 Living within the legal framework 

During Confed17, NHS Improvement’s CEO Jim Mackey stated that that it is possible to get “90% of the way there” with ACSs and accountable care organisations within the current legislative framework – “but we need to prove it”. This came after health secretary Jeremy Hunt suggested that legislation around STPs is likely to be pushed until after Brexit negotiations are concluded. And even then, it is questionable whether the government will be able to legislate without cross-party support for its reform programme. 

Asked about the legal constraints surrounding STPs and ACSs, Dodge said: “The job of NHS England is to live within the legislative framework that Parliament has set. There has been speculation as to whether there would be primary legislation, and the Conservatives’ manifesto alluded to that prospect. I think others have speculated that this would be less likely now given the current status of politics. 

“Obviously, the Department of Health had been talking to its partners as to possible legislative change. Should the government wish to engage further at some stage we will offer our input. But we must do as much as we can to deliver within the existing legislative framework.” 

There is a lot that people can do within the current framework, noted Dodge, who helped set up the New Models Care programme and some of the work on STPs — “but the most important thing is getting the relationships right and then getting on with the service design”. 

“Arguably, we can all fixate a little bit too much on the anatomy of the health service and a little bit less when we need to focus more on the physiology of how it all connects,” he said. 

The NHS England director added that the work already undertaken as part of the reform agenda, in terms of looking at how to support the optimal planning of services and providing some of the challenge around redesign, tackling variation and improving outcomes, has to continue – irrespective of any technical changes in the system. 

No single answer on CCG mergers 

One potential technical change, for instance, is further CCG mergers. “On one level, what we are doing with things like the STP process and devolution is saying, ‘actually it is quite a hard job for individual CCGs to do everything perfectly entirely by themselves’. They need to engage their local authority partners, their core providers, including acute providers, in developing their vision of where they want to get to and executing against that,” said Dodge. 

Asked whether there will be more CCG mergers to facilitate greater collaboration across footprints, Dodge stated that NHS England doesn’t have a view that there is a single right answer across the country on this. 

“I know that some people have found that hard to believe, and that there must be a secret kind of plan here and that we have a magic number in mind,” he said. “But we don’t have a magic number. But there are trade-offs in getting the local relationships right in places and getting the geographies right around some of the challenges. 

“Those dilemmas apply differently across different services. For example, you need to plan hyper-specialist services on a different footprint from, say, other specialist services differently from a lot of A&E services, differently from your integrated primary and community hubs. The art is partly about how we can plan and commission services at those right levels. What we have tried to do is avoid a headlong rush into people thinking the answer is to merge, because that could potentially be a big deflection. But equally, we haven’t wanted to stand in the way when there are compelling reasons to merge – hence the very clear criteria we set out. 

“We are also, naturally, seeing the emergence of the sharing of management functions between CCGs and an increasing number of shared management teams. If you go talk to NHS Clinical Commissioners, that is exactly the right direction of travel.” 

One thing that ACSs have been tasked with is how to join up the local budget in a meaningful way across the footprint, extending the work that CCGs have been doing in their areas. 

“We need to look at how we can take that work, and progress it in a way that feels more meaningful to the ACSs,” said Dodge. “We’ve also noted that there is an element of ‘horses for courses’ for each of the individual systems. 

“One of the emerging templates is the work that we have done with Greater Manchester  (GM) with regards to devolution. If you take away the devo wrapper and instead take the underlying principles of what that has been about –  how can we transfer more clearly a sense of responsibility for managing the local system, how can we support the horizontal integration, the vertical integration, and the sense of local systems coming together – what we are doing with ACSs is very similar to what is going on in GM.

“This will get codified in an agreement between the national organisations and the local ACSs and what responsibilities they take on at different stages. There is a development group, so we are co-designing this work with the ACSs that Simon announced at Confed and what this means for them and when. At the end of the day, our aim here is to enable.”

First wave of ACSs 

  • Frimley Health
  • South Yorkshire & Bassetlaw
  • Nottinghamshire
  • Blackpool & Fylde Coast
  • Dorset, Luton (with Milton Keynes and Bedfordshire)
  • West Berkshire
  • Buckinghamshire
  • Devo Surrey

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Image - © Stefan Rousseau - PA Wire

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