Uncharted territory – what could 2018 bring for STPs and accountable care?

As sustainability and transformation partnerships (STPs) and accountable care systems (ACSs) gain momentum and a handful of areas seek to implement accountable care organisations (ACOs), the year ahead could shape how health and care is delivered in the future.

The prize for getting it right will be improving patient care, integrating pathways and getting better value from collective coffers. But this is uncharted territory and with parliamentary time tied up with Brexit, aspirations for new models of accountable care must be delivered within the existing legal frameworks. Here we explore five of the wider implications which we hope to see in the year ahead:

1. A clearer public narrative. As STPs/ACSs and ACOs gain greater prominence in the public eye, the national bodies will need to deliver a convincing narrative in support of their development, as Sir Bruce Keogh did recently. The development of STPs has raised suspicion in some quarters, and there is a real need for public and non executive scrutiny of emerging plans. The term ‘accountable care’ has also received a mixed response with fears it could open the door to privatization and NHS England faces two legal challenges to the ACO contract, which has recently been paused. Locally, STPs may require national ‘air cover’ to deliver significant change which may mean difficult choices or piloting and refining new ways of working. Trusts will need time to engage their populations, build local political support, ensure plans are clinically led, and gain input from non executives and governors. In short, building public support for any new approach to health and care will need significant investment nationally and locally.
2. Learning from new approaches to strategic commissioning: The renewed focus on system collaboration, and population health, has real significance for commissioning in those areas where ACS and ACO plans are progressing. It is fueling diverse approaches including the planned merger of STPs in the north to offer a larger footprint for strategic commissioning, an increase in CCG mergers and shared accountable officers, collaborations between CCGs and local authority commissioners; the emergence in one area of the trust as an ‘integrator’ and the development of ACOs. The proposed procurement of at least four ACO contracts this year means the emergence a more streamlined and strategic commissioning function in those areas complemented by ‘tactical’ commissioning undertaken by the provider holding the contract. These are all exciting developments and there will be much to learn from those taking the plunge first in weighing up the relative benefits, costs and skills required for each approach.
3. Testing out a new balance of regulation and oversight: Given that statutory responsibilities rest with individual organisations (largely trusts and CCGs) there is a risk that, in the short term, trusts could face a two tier system of organizational regulation and system level oversight with the potential for double jeopardy. We know that the national bodies are committed to avoiding this and look forward to learning from the experiences of the ACSs which have negotiated freedoms and flexibilities in return for taking collective responsibility for performance (and in some areas a shared control total) across the system. We also hope to see NHS England and NHS Improvement align their messaging much more closely this year.
4. Trusts will invest in ‘the art of the possible: ‘The recent recognition by NHS England that FTs and trusts could act as the natural host organization for the formation of an ACO is very welcome. In fact, as our recent publication with Hempsons made clear, there are a number of ways in which trusts can already form new organisations and partnerships to deliver integrated care. In the year ahead we expect to see more collaborations between trusts, either in group models, through merger or shared management teams. We also expect to see the continued development of vertical integration with primary and social care.
5. The pace of change will vary – but everyone needs support. STPs are developing at different paces across the country, largely dependent on the quality of historical relationships as well as population size, geography and patient flow. Despite this there has been a worrying tendency for STPs to become the default footprint for delivering a range of national policy initiatives which they do not all have the local mandate, capacity or infrastructure to deliver. While funding and support for those ACSs progressing quickly is welcome, it is only right that trusts and their partners - and taxpayers - benefit fromsupport for STPs at all stages of development. We certainly acknowledge that NHS Providers, and other membership bodies, have a role to play here, along with the national bodies.

More collaborative arrangements between different health services and social care have the potential to transform patients’ experiences. But how we navigate choppy waters in the year ahead may well determine how far STPs and accountable care become the natural mechanisms to deliver this in the longer term.

How we navigate choppy waters in the year ahead may well determine how far STPs and accountable care become the natural mechanisms to deliver this in the longer term.

Miriam Deakin    Co-Director of Development and Engagement

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