Systems not structures – Getting to grips with the principles of accountable care Peter McNaney - Chair, Belfast Health and Social Care Trust Emma Holden - Health and Social Care Board and Department of Health NI Phil McCarvill - Deputy Director of Policy, NHS Confederation Chris Wood MD - Vice President, Intermountain, Utah

Accountable Care Systems: getting to grips with the principles Emma Holden Health and Social Care Board / Department of Health

Case for change Population needs and expectations Workforce and Financial challenges Organisations and silos Empowering a population health agenda Innovation and scale Briefly set out the drivers towards accountable care models in NI and other jurisdictions / problems it seeks to address – drawing heavily on Expert Panel report but also making reference to the FYFV and Kings fund work Key Message: Many common challenges, and greater autonomy and accountability across providers and new organisational forms are increasingly being seen as way to address this

Concepts Accountable Care Systems Accountable Care Organisations Clinical Networks Sustainability & Transformation Plans Population Health Models Alliance Contracting Place based systems of Care Key Message Many differnt But overarching theme is how to provide continuity of care designed around the needs of the patient Integrated Care

Characteristics Shared leadership and mutually accountable Providing continuity of care in an organised way Integrated collective provider models - systems not structures

New Working Arrangements Components Size and Scale Defined population New Working Arrangements New support tools User Engagement Outcome Based Lessons learned from ACS elsewhere provide evidence of the key components that can be put in place to drive more integrated working without the need for structural reform: The population footprints must be of sufficient size to manage the majority of the population’s care needs. Take accountability for managing variations in demand and expenditure, ability to take decisions to change the delivery of care, and support local partnership working and risk sharing. A defined population, where the new model of care can be delivered at pace, focusing on the stratified risk of that population . Shared leadership, shared accountability and devolved budgets. The need for GPs, hospitals and other care providers to build new partnerships that are supported through new business models. Support tools that include shared information, accessible patient and client records and a capitated funding system that incentivises an integrated provider response. Engagement with patients/service users at population, service and individual level. Cost and quality measures which are measurable, comparable and outcome based.

Complexities and Choices Structure and culture Top down and bottom up Quick and slow Manage and empower

Conditions New models of care & outcomes System & clinical leadership Quality improvement & innovation Technology & information

Accountable Care Dr Phil McCarvill NHS Confederation Twitter - @phil_mccarvill

Accountable Care Focus on: What is happening within the NHS and wider system in England? Draw on a little of what we know from what is happening internationally. Focus on what is best for people, not what is the optimal organisational form. Identify issues we need to consider.

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Why Accountable Care Approaches, why now? Ageing population Demand pressures As health and other care needs change so the NHS must change and respond. Delivery of care across different settings We cannot simply deliver more of the same. Economic analysis – a resource for the Confed

Accountable Care Focus effort on those who are the heaviest users of services. In the US - Almost half of the nation’s health care spending is driven by the top 5% of the population with the highest spending, while the top 1% account for more than 20% of total health care costs. Zubin J. Eapen & Sachin H. Jain, Redesigning Care for High-Cost, High-Risk Patients.

A System-wide approach to care People require care from a range of settings – primary care, community services, nursing and care homes, their own homes and in hospital. Physical and mental health. The gaps in care and between organisations are not good for the individual or the system. Gaps impact on experiences of care and efficiency of services. Economic analysis – a resource for the Confed

Accountable Care in England Multi-speciality Community Provider (MCP) Primary and Acute Care Systems (PACS). Vanguard areas testing out variations of providers, payment systems and models. Challenge now to encourage take up beyond existing Vanguards.

Important to acknowledge scale of task Fundamental shift in approach: From hospital to community From competition to collaboration To more person focused responses From a system will IT is necessary, to one in which it is pivotal.

Issues to consider Payments and incentives – moving from an activity based system to capitated/population based budgets. Risk sharing – capitated budgets. Multiple organisations involved – need to ensure alignment. Case management systems – risk stratification across organisations.

Issues to consider Link between hospital and what happens in primary care and community services. Access to data – Alzira (traditionally a challenge in the UK context. Who leads – large acute hospitals, primary care…? Important role of regulators – NHS England and NHS Improvement. Conversation with the public – common to all new approaches – take people with us. Support needed to make this happen.

Accountable Care Systems Five Year Forward View: Next Steps document appeared to shift the focus from Accountable Care Organisations (ACOs) to Accountable Care Systems (ACSs). First 9 potential ACSs Need to understand the difference – more or less complex?

Wider Picture Must be seen alongside the need for a long-term solution to social care funding in England. Legislative change required? Minor or more fundamental change? Require support for all 44 STP areas. Emphasis on partnership approach. Engagement with the public.

Conclusion Important we learn from elsewhere and within the UK. That we adapt the learning to fit local community needs. We support organisations and professional to make the shift. Engage public throughout. That we take the time needed to make it work.