Areas targeted to become ‘evolved STPs’ with much bigger freedoms

Accountable care systems (ACSs) will now be considered an ‘evolved’ version of an STP that is working as a locally integrated health system, NHS England’s Five Year Forward View progress report, or delivery plan, has confirmed – and this will come paired with much greater freedoms for local organisations.

“[ACSs] are systems in which NHS organisations (both commissioners and providers), often in partnership with local authorities, choose to take on clear collective responsibility for resources and population health. They provide joined up, better co-ordinated care,” the plan explained.

“In return they get far more control and freedom over the total operations of the health system in their area; and work closely with local government and other partners to keep people healthier for longer, and out of hospital.”

Specifically, ACSs are STPs, or groups of organisations within an STP sub-area, that can agree an accountable performance contract with NHS England and NHSI that can “credibly commit to make faster improvements in the key deliverables set out in this plan for 2017-18 and 2018-19”.

Together, they will manage funding for their defined population, committing to shared performance goals and a financial system control total across CCGs and providers, NHS England explained, adding: “Thereby moving beyond ‘click of the turnstile’ tariff payments where appropriate, more assertively moderating demand growth, deploying their shared workforce and facilities, and effectively abolishing the annual transactional contractual purchaser/provider negotiations within their area.”

ACSs will be able to create an effective ‘collective decision-making and governance structure’, aligning the ongoing and continuing individual statutory accountabilities of their constituent bodies.

They will also be responsible for demonstrating how their providers will operate on a ‘horizontally integrated basis’, whether virtually or through actual mergers; show how they will simultaneously also operate as a ‘vertically integrated’ care system, partnering with local GP practices formed into clinical hubs; deploy “rigorous and validated” population health management capabilities that boost prevention; and establish clear mechanisms by which residents within the defined population will still be able to exercise patient choice over elective care.

In return, they will be given the ability for the local commissioners to have delegated decision rights in respect of commissioning of primary care and specialised services; a devolved transformation funding package from 2018, potentially bundling together national funding for the GP Forward View, mental health and cancer; a single ‘one stop shop’ regulatory partnership with NHS England and NHSI in the shape of streamlined oversight arrangements; and the ability to redeploy staff and related funding from NHS England and NHSI to support the work of the ACS.

“This is a complex transition which requires careful management, including of the financial framework so as to create opportunity while also reducing instability and managing risk. That’s why ACSs require a staged implementation,” the plan said.

“This also provides the opportunity to prove their ability to manage demand in ways that other areas can subsequently adopt. We expect that candidates for ACS status to include successful vanguards, ‘devolution’ areas, and STPs that have been working towards the ACS goal.

“In Q1 2017-18, NHS England and NHSI will jointly run a light-touch process to encourage other STPs (or coherent parts of STPs) to come forward as potential ACSs and to confirm this list.”

Likely candidates already include Frimley Health; Greater Manchester; South Yorkshire & Bassetlaw; Northumberland; Nottinghamshire, with an early focus on Greater Nottingham and the southern part of the STP; Blackpool & Fylde Coast, with the potential to spread to other parts of the Lancashire and South Cumbria STP at a later stage; Dorset; Luton, with Milton Keynes and Bedfordshire; and West Berkshire.

“In time, some ACSs may lead to the establishment of an accountable care organisation (ACO). This is where the commissioners in that area have a contract with a single organisation for the great majority of health and care services and for population health in the area,” NHS England explained.

“A few areas (particularly some of the MCP and PACS vanguards) in England are on the road to establishing an ACO, but this takes several years. The complexity of the procurement process needed, and the requirements for systematic evaluation and management of risk, means they will not be the focus of activity in most areas over the next few years.”


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