The words ‘accountable care’ have become synonymous with problems and concerns. The latest ‘pause’ announced to address concerns will do little to change that in the short term. But to fall over these words is perhaps to miss the genuine benefits of the programme of work underpinning them.
We discussed these benefits and the key enablers required to unlock them at two roundtable events last year. At our first event in May we asked whether the newly re-named sustainability and transformation partnerships (STPs) could ever truly succeed without a change in the underlying law. Unsurprisingly the answer was more complex than a simple yes or no.
What was striking at the event though was the enthusiasm among participants for the original objectives behind accountable care models introduced by the ‘Five Year Forward View’ – the better integration of health and social care; the breakdown of traditional organisational silos; and the shift of focus from those organisations to the health needs of the local population. The enthusiasm was striking because those same participants could also identify a long list of challenges that still had to be overcome before these objectives could be achieved.
In November 2017 we convened a second roundtable in a different part of the country to assess how this concept of ‘accountable’ or ‘place based’ care was evolving across the NHS. Once again, the enthusiasm was obvious and, whilst not unwavering, was just as strong as it had been at our event in May.
Participants at both events shared local success stories and agreed that the key enablers for this success within accountable care collaborations were:
- Clarity of vision – agreement both on the defined population covered and desired outcomes for that population
- Alignment of organisational incentives and payment with that vision to ensure they encourage collaboration and achievement of desired outcomes, rather than driving any other unhelpful behaviours
- Accountability – recognition that the impact of collaborative working on individual organisations needs to be managed carefully. Whilst energy is spent identifying populations and outcomes, organisations must not lose sight of their existing functions and statutory responsibilities. Robust governance structures could still be flexible
- Leadership and culture – not surprisingly strong and inspirational leadership is widely considered essential to maintain the momentum required for collaboration. Interestingly, though there was also recognition at our November event that more than one leader may be appropriate, many considered it unrealistic to expect one person to have the expertise to lead all aspects of the collaboration. Additional leadership roles might also address the concerns raised by our May participants that the original STP leaders were not given sufficient support to allow them to concentrate properly on the role
One noticeable shift between May and November was the views on operational form. At both events there was agreement that form could only be decided once the aims of the collaboration had been agreed. However, whilst in May it seemed that areas were on the cusp of moving to development of form, the feeling in November was that there was already too much focus on the ‘what’ of the form and that more should be done to emphasise ‘why’ collaboration was happening.
Concerns were expressed about the role of acute providers dominating the discussions and also that a series of ‘must do’ reporting requirements for collaborations issued by central bodies had diverted energy and created resentment around the concept of accountable care. Added to this, negative press about the impact of accountable care collaborations was also affecting progress. Those in the room wanted much more emphasis on why collaboration was a good thing and how it could take many different forms depending upon population needs.
If we are to draw any conclusions from the two roundtables held so far, perhaps key ones would be:
- There is enormous enthusiasm in the NHS for the positive patient benefits attached to integration of health and social care and the development of new ways to deliver that care to a local population. It is this enthusiasm that will drive the much sought after transformation of those services. Successfully motivating people to work differently takes thought and time. The full value of collaboration will never be unlocked simply by imposing plans on people or by trying to achieve success by shortcuts, because enthusiasm is then lost
- The enthusiasm can be threatened by sovereignty disputes based on historical roles held by organisations. These are more likely to arise where organisations do not understand or accept their new roles within the collaboration. Clarity of vision and alignment of incentives to desired outcomes is essential. Equality of voices within a collaborative group is needed and may take time to establish
- The enthusiasm can be threatened by external pressures both at organisational and national level. The requirement for strong leadership is a given, but those leaders also need to inspire to maintain the focus and momentum in the face of external pressures and diversions. They need to think differently about culture and behaviour to reinforce collaborative working. It may be that more than one leader is appropriate, that ‘power’ is shared. After all, this model fits a more collaborative working style
So what does all this mean for the evolution of accountable, place based care? It means that if we are to avoid losing the benefits of this programme, collaborative groups need flexible environments in which to work, possibly for a long time, to clarify and embed their vision. Individual organisations need to know their voices will be heard in that environment, but also need to feel secure about their own individual accountability.
There is increasing acceptance that the transition to a new accountable, place based model of care is complex, though this view is focussed more on the complexities of the regulatory environment in which organisations are operating. There also needs to be acceptance of the fact that regardless of those regulatory hurdles, it takes time to create a long lasting collaboration; acceptance that successful transformation takes the form of a series of small steps over time, not in a single transaction. If the journey is a long one though, it raises concerns about accountability of the individual organisations involved.
If organisations can concentrate on the creation of flexible environments within which they can operate; if focus can shift from the evolution of accountable care as an end state to ‘accountable evolution’ as an on-going process, then not only can risks be better managed for individual organisations but the ‘why’ and the ‘what’ of the collaboration can be addressed at the same time.