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Greater Nottingham ACS: Taking care of something precious

Dr Stephen Shortt, GP and clinical lead for developing an accountable care system in Greater Nottingham, talks about the collective work to join up health and social care in the region.

Any work to transform the NHS must begin with an honest conversation; an open dialogue between patients, staff and system leaders that acknowledges a simple truth: our health and social care system, as is currently designed, configured and experienced, is not sustainable for the future.

We must be honest: the most admired public healthcare system in the world is straining under an ever-increasing burden of demand. As a GP, I see this daily. Our system is fragmented, confusing, inefficient and expensive. Experience of health is often unequal, the provision of evidence-based healthcare is uneven, and the challenge of coordinating care in an increasingly complex and fragmented delivery system is widely acknowledged. And, worst of all, I believe that this means that the care we give to our patients risks falling short of the standard we would wish for them. An inexhaustible supply of funding to fix this simply does not exist.

It is remarkable that this complex system produces such good outcomes as it does. I would argue that this performance is being sustained by the professionalism and effort of the thousands of heroic clinicians, support staff and managers across the system. But, much like the funding, this professionalism and effort is also not inexhaustible. As part of these honest conversations, we are all starting to acknowledge that the job is becoming far harder. 

These problems haven’t emerged overnight and have been debated continuously over a number of years without us ever seeming to move any closer to a solution. 

We have, though, now created a genuine opportunity.

The work of the Nottingham and Nottinghamshire Sustainability and Transformation Partnership –  and the selection Greater Nottingham to be the early focus of an accelerator site for the development of an accountable care system – gives us the chance to work together to develop something that will meet the future needs of our local population.

Clinicians and managers in our CCGs have come together with the leaders of the local authorities, and with the clinical and managerial leads of all our main providers of healthcare services – hospitals, mental health and community. They have committed to putting aside organisational self-interest and to work with urgency as ‘Team Greater Nottingham,’ if you like, to improve the health of the population, to improve the quality of health and care services, to make best use of all the resources made available to us, and more: to be accountable to each other and to our citizens for doing so. This is what we mean when we talk about an accountable care system​. Not a structural reorganisation, but a new way of working.

Most of our citizens would think this is how a comprehensive public health and care system already operates. And yet, of course, it doesn’t. There are components of the current system that work against these objectives, and the way the system is organised and operates often frustrates our best intentions.

A tailored system

The task we have set ourselves is to design, create and implement a bespoke, locally-specific and fit-for-purpose accountable care system. By this we mean:

• Aligning commissioners and providers around the needs of local people, with providers having system-level accountability as well as organisational accountability;
• Blending and integrating GP, community and hospital resources and capabilities into a single risk-bearing entity to manage the entire continuum of care from end to end;
• Creating a sustainable transformation based on value and the relationship between outcomes and costs.

We have acknowledged that we are problem-solving for a very complicated world. We have to move from a set of often insufficiently productive, competitive and even, on occasion, adversarial relationships and build a new culture and collaborative system across health and social care, which is up to this very considerable task for 750,000 people with £1.5bn of recurrent annual resource.

It will be hard work, it will take time and, of course, success is not taken for granted. We will need to develop and put in place new system and organisational capabilities, relationships and responsibilities. It will require new models of cross-organisational care underpinned by both new and improved clinical and managerial systems, new business, IT, actuarial and analytical skills, and new governance arrangements for the common resource. And, finally, leadership.

Past experience suggests drawing up grand plans is difficult, but swift implementation at large scale is harder still. As many have observed at present, we have insufficient know-how and no experience. Our track record of implementing and executing large-scale change is not good. No one has achieved this before in our country – but others have achieved it elsewhere in the world, most notably in parts of Europe, New Zealand and in some parts of the United States.

We’ve commissioned an external adviser called Centene UK to help identify and develop the essential building blocks, functions and processes needed for a high-performing and sustainable accountable care system. We are being open by saying that we don’t have the experience or, at the moment, the skills to do this ourselves, but want to learn from others who have already been successful.

We have been inspired by the progress made by colleagues​ elsewhere, including in the acclaimed Alzira model in Valencia, Spain. It successfully developed a highly effective model of population health management and better integrated the teams that provide healthcare while making better use of the resources available. This all leads to better outcomes for its local population. For our patients, application of this thinking will simply mean:

• We will identify and support patients in greatest need;
• We will provide individuals and carers with the tools and support to enable them to take more control of their health and wellbeing;
• We will deal with the whole person, especially where patients have both physical and mental health problems;
• We will prioritise health promotion and promote wellness to the wider population;
• We will intervene early and prevent progression of disease;
• We will provide more care closer to home in the community and hospital care for those who really need to be there;
• We will manage and improve transitions from one part of the system to another, with fewer barriers between services from the NHS and local councils.

Having honest conversations

Over time we will develop our own levels of expertise and knowledge and become more self-sufficient. But we want to make sure we give ourselves the best chance to get this right. It comes back to having an honest conversation.

These conversations are often difficult. In Greater Nottingham, we have ongoing engagement with patients and the public about our work to join up health and social care more effectively. Passions run high at these meetings; I believe it’s because we all feel so strongly about protecting the NHS we all hold dear. 

What I and my colleagues feel, above all, is a slightly old-fashioned value: the sense of stewardship, the feeling that we have been entrusted to take care of something precious, and that we have an obligation to leave it in a better condition than before.

This accountable care system is not a universal solution for all the challenges we face, but it is the means of transformation to a higher-performing health and care system. It isn’t going to be easy. But I believe we have the commitment from everyone involved in health and care to go further and faster for the people of Greater Nottingham.

Top image ©SAKhanPhotography

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