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Population-Based Accountable Care in the National Health Service

Article · October 24, 2016

In the face of economic and demographic pressures, health systems globally are experimenting with new models of accountable care. The National Health Service (NHS) in England is part of this trend. It has now been just over a year since the NHS launched an innovative program to test and implement a number of new care models, the objectives of which are to reduce variation in care quality, to improve population health, and to help achieve financial sustainability in the provision of health care.

Although the terminology is different, two of these new care models — multispecialty community providers (MCPs) and integrated primary and acute care systems (PACS) — have strong similarities to accountable care organizations (ACOs) that are developing in the United States and elsewhere.

Both MCPs and PACS are population-based health-care models seeking to bridge the historic divisions between primary, community, mental health, hospital, and social care services. Central to both models is the role of General Practitioners (GPs), family doctors who provide primary care to the local population.

The main difference between the two models is the scope of services covered by the provider. MCPs are integrated out-of-hospital providers that bring together primary care, community-based health, and social care services for all local patients. Under the MCP model, the provider does not directly operate most core hospital services. PACS, conversely, are whole-system health and care providers that operate all core hospital services.

Similar to the Centers for Medicare and Medicaid Services (CMS) approach of selecting and evaluating a number of innovation sites, the new care models program is supporting 23 “vanguards” across England that are implementing these new models. These sites are local health systems with an average population size of between 100,000 and 400,000. They typically include all of the local health and care providers within each local region and are being co-developed in cooperation with the local payors (“commissioners” in NHS jargon). The national program offers transformation funding to these sites (with approximately £100m provided last year), provides technical and policy support, and is running a national evaluation to assess the impact on a range of quality and efficiency measures. The objective is not just that the vanguards will succeed on their own terms but also that we will be able to develop blueprints that can be adopted across the country.

New Care Models in Action

Through their implementation efforts, the vanguards are helping to identify the most important features of these new care models.

One key feature is a deep understanding of the local populations’ needs. To that end, the vanguard sites are using integrated datasets and predictive analytical tools to identify, anticipate, and respond to the diverse needs of individual patients. For patients with the most complex needs, many sites are experimenting with extensivists (physicians who care for patients both before and after their hospital stay), such as at the Symphony Care Hub in Somerset.

Another key feature is the systematic use of multidisciplinary teams, such as the PRISM (Profiling Risk, Integrated Care and Self-Management) teams in Nottinghamshire, which provide coordinated, preventative treatment for patients who are deemed to be at high risk of future hospital admission.

New models of specialist care are also emerging. We expect to see the traditional model of outpatient care fundamentally changing, particularly for the most common long-term conditions such as cardiovascular disease and diabetes. We can already see some glimpses of this trend. In Morecambe Bay, for instance, an electronic advice service that allows GPs to seek guidance from specialists is significantly reducing unnecessary hospital appointments.

Perhaps the most significant game-changer is the way in which the vanguards are seeking to redefine relationships between patients, communities, and their local health and care services. Common approaches include the use of health coaches and community health workers. Finally, vanguards are seeking to exploit the synergies between health and other local government services, including fire, police, and housing.

None of these features of the new care models are themselves revolutionary. The innovation is in implementing them in a coordinated way, at scale, and for the long term.

To achieve these objectives, the new care models will need to be backed by new business models that will fundamentally change the way the NHS buys and pays for services. The new care models will operate under whole-population budgets for all of the services that they provide, replacing the fragmented payment systems that currently exist. This approach will involve the development of new contracting and organizational arrangements that will bring together health and care providers. A new voluntary contract for general practice is being developed to facilitate these changes. We expect these new approaches to be implemented in 2017.

Creating the Conditions for Success

So, will the NHS reforms work? After all, the NHS has tested other versions of such reforms before, including Care Trusts and Integrated Care Pilots. It is too early yet to say. The first new contracts will not be awarded until next year, so the evidence base is still limited. But I think three factors will increase the likelihood of success:

  1. First, the NHS needs to achieve the appropriate balance between defining how these accountable care models will work nationally and still allowing for local adaption and innovation. We are trying to navigate a middle way between a prescriptive one-size-fits-all approach and letting a “thousand flowers bloom.”
  2. Second, to achieve widespread adoption of accountable care models, the NHS will need to make it more difficult and less appealing to continue with old care models while making it more appealing to put the new ways of working into practice. Past reform attempts have failed in this regard, but the NHS is now starting to “rewire” the system to achieve this goal by instituting new payment models, new regulatory approaches, and a planning framework that supports accountable care.
  3. Third, system leaders need to hold their nerve. This kind of large-scale change takes time, but politicians and the public are rightly impatient for such change. I recently spent time at Gesundes Kinzigtal, Germany’s integrated-care success story. It wasn’t until the fourth year of its new population-based health contract that the system started to deliver financial savings. Meanwhile, the most successful integrated delivery systems in the United States, such as Geisinger Health System, have taken decades to mature into the systems that we see today.

The ultimate test for these accountable care reforms in the NHS will be something more visible. Success will be achieved when patients demand access to these systems and health care professionals prefer to work in them. On this measure, there is still much work to be done.

 

For more information about the new care models program, visit www.england.nhs.uk/vanguards.  

This article originally appeared in NEJM Catalyst on July 27, 2016.

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