Archive for November, 2012


Accountable care organisations are in danger of becoming yet another passing trend in the NHS, without them really being properly understood.  They have been talked about by some, but I suspect most aren’t really clear what an accountable care organisation really is.  Until recently, this was certainly true for me.  However, having looked into it, I think they have much to offer current thinking in the NHS.

In the US the starting point for Accountable Care Organisations is what they term the ‘triple aim’.  The triple aim is the requirement for each healthcare organisation (commissioner and provider) to deliver three things simultaneously: quality patient experience, population health and cost effectiveness.

Previously the US has only focused on quality of individual patient experience.  As you will be aware, this has led to it spending 18% of GDP on healthcare with a large proportion of the country uninsured.  Out of necessity those leading US healthcare have understood that embedding the triple aim within all healthcare organisations is critical to the development of an effective healthcare system.

Accountable care organisations start with the premise that to meet the triple aim, the primary focus must shift to keeping people healthy.  The highest quality health experience is not getting sick in the first place.  It is avoiding diabetes, not receiving the best treatment for diabetes once I have it.

Accountable care organisations in the US are providers not commissioners.  The contracts they receive are not activity based.  Payment by results encourages more treatment of the sick, not prevention of sickness.  The payments are capitation based.  Providers have a cost envelope to deliver care within for a population.  What they don’t spend they can keep.

Healthcare providers are, understandably, resisting the move to accountable care organisations.  In their eyes it shifts the risk from the payer to the provider.  It does.  That does not, however, mean that it is wrong.  A prevention mentality amongst providers is critical to changing the healthcare system.  The more progressive US providers understand this and are, somewhat reluctantly, taking this on.

Another key difference between the US system and the NHS is that they do not have this clear distinction between primary and secondary care.  In the NHS providers deliver either primary or specialist care.  In the US it is not uncommon for a healthcare provider to own specialist and primary care facilities. And what they are doing is strengthening primary care.  They are building something called the Primary Care Medical Home (PCMH), which is like QOF but focused on impact, rather than collection of the extra income.  They are taking case management seriously and starting to show really powerful results.

We should question why in the NHS we cling so tightly to this separation between primary and secondary care.  Integration between the two needs to happen. We cannot continue with secondary care throwing bricks at primary care for failing to control demand, and primary care accusing secondary care of fraudulent up-coding.  Either primary care harnesses clinical commissioning and forms a new relationship with secondary care, or hospitals start buying GP practices.  With no new money, something has to change.

As clinical commissioners we should learn from the US that the notion that payment by results allows activity to be shifted from secondary to primary care is flawed.  It simply encourages more treatment activity, leaving less money for prevention.   We must change our payment models to ones based on capitation payments.  Providers must innovate to make a profit on this basis. This will change how general practice operates as well as how hospitals operate.

Accountable Care Organisations are a development in the US we must watch closely.  As the Affordable Care Act (or Obama-care) spreads across the US we will see this grow.  We are better placed to apply these principles in the NHS, if only we can get outside of our organisational boundaries.

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As we move into winter and hospitals move more regularly into red and even black alerts, local escalation is critical.  It is important that the system is managed effectively, and strong multi-agency responses are co-ordinated.  So whose responsibility is this?  While it is clear that the NHS Commissioning Board (NHSCB) is responsible for leading the response to any category 1 train-crash type incident, it is less clear who is responsible for the more common ‘system in crisis’ issues.

The guidance, however, is relatively straightforward.  Clinical Commissioning Groups are category 2 responders.  Really this means that in the event of a major incident we have a responsibility to co-operate and share relevant information with other category 1 and 2 responders.  However, the Health and Social Care Act says that, ‘The Board and each clinical commissioning group must take appropriate steps for securing that it is properly prepared for dealing with a relevant emergency’.

‘Relevant emergency’ is defined in the Act as any emergency which might affect the CCG (whether by increasing the need for the services that it may arrange or in any other way).  The NHSCB must take steps to secure that each CCG is properly prepared for dealing with a relevant emergency.

On this basis it is clear that each CCG is responsible for dealing with the ‘system in crisis’ issues, and the NHSCB is responsible for ensuring the CCG is set up correctly for this purpose.  But to date the implementation has not really followed the guidance.  Around the country (although it varies) the Local Area Teams are starting to assume a responsibility for traditional Silver and Gold calls when the local system overloads.

While this is understandable if CCGs do not yet have the necessary capacity or infrastructure, it is important that CCGs grasp the nettle that and take this responsibility on as quickly as possible.  The opportunity of clinical commissioning is to drive the response to these crises in new, innovative and more effective ways.  Responses that are built on relationships between clinicians across all sectors can ensure that not only is today managed effectively, but that changes to systems are put in place that mean the crisis is less likely to happen in future.

At the heart of the strategy of many CCGs is the shift of activity out of acute setting into the community.  In the past acute trusts have used these crises as a mechanism to demonstrate that PCT demand management strategies are failing.  In the new world this needs to change.  CCGs can use these crises to understand where the capacity in the community is lacking, and use the urgency of today to fill this gap.  Each crisis is not a demonstration of failure, but an opportunity to put another building block in place to create tomorrow.

Many health and social care organisations have become cynical and often critical about the silver and gold responses.  They are often seen as bureaucratic and adding little real value. In some places they are reduced to pure status-reporting with no real action coming out of them.  As CCGs take over responsibility for these responses it is critical that they embark on honest conversations with their health and social care partners as to how this could change.  A partnership approached to the redesign of the response to these crises is likely to be well received.

This issue is critical to CCGs at this early stage of their development.  Many acute trusts and Local Area Teams do not believe CCGs are capable of system leadership.  Ensuring that the response to crises is timely and effective is a highly visible route to building confidence in CCGs.  It is vital that CCGs grasp this with both hands.  It is no good CCGs having grand plans for tomorrow if they cannot manage today, and the reality is that clinically led CCGs are set up to manage today much more effectively than any commissioning organisation in the past.  Leaving it to others now may seem easy in the short term, but will store up trouble for the future.



Most CCGs are working on some form of system of case management of those at high risk of admission.  Debates in this area are now tending to focus on the appropriate use of risk stratification technology.  It has become almost an IT software debate as to which is the most effective, the implication being those with the best IT software will have the best results.

I have been involved in a number of case management systems.  They have struggled to be successful as programmes largely because the total outlay in the infrastructure to put them in place has not been offset by a greater (or even similar!) reduction in acute activity.  The cost of the additional nurses in the community, social services input, and GP and practice time has been more than any reduction in acute activity.

We can demonstrate that the cohort being case managed cost less than they used to, or even less than a control group.  Finance colleagues struggle with this because there is no actual money for them to put their hands on.  We then get into technical arguments about ‘regression to the mean’ (that those at high risk of admission were on the road to recovery and so would have cost less anyway).  Hence the conclusion that the identification of the right client group, and so the use of the right IT software, is the ultimate key to success.

There is an article on case management that I think should be mandatory reading for every CCG Accountable Officer.  It was published in the New Yorker magazine (!) in January 2011, and is entitled ‘The Hot Spotters’ by Atul Gawande.  It is easy to find on the internet, or you can access it here

This article talks about the work of Jeff Brenner in Camden, New Jersey, and how he developed case management.  Its roots are not in saving money but in treating people as people.  It does save money because individuals from health partner and build relationships with individuals in the community.  They do what they can to give them what they need and to help them take responsibility for their own lives.  Saving money is the bi-product, because it prevents the development of ever increasing need for episodes of care.

In the NHS we have been distracted by risk stratification tools and are wandering down a blind alley.  At the heart of case management of those at the highest risk of admission lies a fundamental shift.  It is a shift away from delivering care on an episode basis, and towards the delivery of care on a human being basis.  The health service may interact with individuals through a series of episodes of care, but ultimately we are treating human beings.  The move to case management should be encapsulating this shift.

The evidence is clear that a very small number of patients are extremely costly, whether it is the 5/50 rule (that 5% of the patients generate 50% of the cost), or Jeff Brenner’s finding that 1% of the patients accounted for 30% of the costs.  The failure to demonstrate the financial return in this country points not to the failure of case management, but to a failure of the way we do case management.

Case management systems in the NHS are funded largely on an episode by episode basis.  Primary care tend to be paid for the number of meetings they have, community organisations are paid for the number of extra visits they do, social workers for the extra packages of care, and voluntary organisations for the additional activity they undertake.  This mindset that we are paid for the actions we take, and not the results of the action, stifles the innovation that is so critical to case management.

We need to find mechanisms to enable staff to care for these individuals however they need to be cared for.  They need to be free to make whatever intervention is necessary.  They need to have the time to try and build the relationships that Jeff Brenner is clear are key to success, ‘High-utiliser work is about building relationships with people who are in crisis’.  As CCGs we are now responsible for the system.  It is the system that is stopping case management being successful, and it is our job to change it.

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What is the goal of health care? This is one of those questions that looks easy, but behind it lies the heart of the transformation that CCGs are trying to achieve.

So what do you think? The most common answer is to provide a service that is there when I need it, to alleviate my suffering and to make me better. If I get sick, a good health care system will return me to health as quickly and effectively as possible.

Wrong.  The goal of healthcare should be to stop me getting sick in the first place.  It should help me understand myself and the impact of the choices I make upon my health. It should help me manage any long term conditions I have as effectively as possible so that I don’t need regular reactive health care.  It should partner me through my life so that I stay healthy.

This paradigm shift in the way we think about health care is needed not just by the receivers of health care, but by the providers of health care.  It leads to partnerships between providers and individual patients, based around their specific needs.  It provides a service that is proactive in managing the needs of patients, and sees the provision of an emergency service as a failure not a success.  We should not be surprised when our patients get sick. Rather we should know in advance that this is going to happen.

In New York Steve Berger was put in charge of a committee to tackle the issue of skyrocketing costs in healthcare.  This committee came to the understanding that this understanding of the goal of healthcare lay at the heart of the change that is required. They understood that there is a massive oversupply of ‘failure capacity’, and that this needs to be reduced.  Alongside this funding systems need to be changed from fee for service payments (i.e. activity based funding like payment by results) towards capitation based funding for the delivery of quality outcomes for specific populations.  Providers should be incentivised for preventing the need for admission rather than for the admission itself.

A health care service designed to prevent the need for health care looks radically different to the one we have today in the NHS.  Its focus is on registered populations receiving the inputs they need at the time they need them (not at the time they choose to present).  It means provider networks designed around population health need. It is affordable in today’s economic climate because the investment required in maintaining health is less than the saving achieved by having less ill health to treat. If we are serious about improving quality and reducing cost this is our only choice.

But what can CCGs do? A this stage we can only do three things.  First we can make it explicit that this is where we are going, in all our communication.  We need to drive the cultural change needed in our communities in their expectations of health care.  We can be clear 100% of the time that this change is needed.  Second we need to be honest that we will make mistakes as we set out on the journey.  We don’t know exactly how to achieve it, and we will need to test out different models. Some will work and some will not.  Third we need to set the expectation that the change we are describing will not be achieved overnight.  It will take us a decade, maybe longer, to figure out the answers.

But if we are clear on our goal, and keep our eyes fixed on it, it is a transformation that CCGs are uniquely placed to deliver.  Steve Berger would love the chance to try and implement his changes in the relatively simple environment of the NHS.  He would start dancing if he had a primary care system set up and capable to drive the change! He may or may not be successful in getting this to work in New York, and may even be stopped dead in his tracks by the election result on Tuesday, but there is nothing to stop CCGs making this happen in the NHS.