Exclusive: Accountable care systems will make 'pathway' for STPs to follow

Details of the benefits for and requirements of the first eight NHS “accountable care systems” are revealed in the memorandum of understanding they have signed with NHS England.

It has not been published but a draft version said there will be a “development group” of the eight ACS leaders and NHS England and I directors, which will “develop a pathway to full ACS status and learning for other STPs to follow”.

“National bodies and initial shadow ACSs will work together to spread this learning to other STPs,” the agreement says, and adds that “learning can be made available to ‘fast followers’”.

Many STPs were generally accepted to have struggled to develop strong shared plans during 2016. They have continued to be developed - particularly on delivery plans for 2017-19, in recent months. Performance information and potentially ratings are due to be published soon.

The draft memorandum of understanding also sets out stringent quality, finance and governance demands on the eight current ACS areas.

These must be met during the 2017-18 “shadow” year, with a final “joint decision” to be made between NHS England and each ACS by February 2018 at the “latest” about whether it can adopt “full ACS status” for 2018-19.

The areas, named by Simon Stevens last month, must be involved in “more assertively moderating demand growth”, meet quality targets and achieve a single system financial control total.

The “confidential” memorandum, which has been agreed in principle between NHS England and the STPs, states:

• The ACS should be working towards a single financial control total this year but the change would “inevitably be bumpy in terms of its impact on the financial position of individual organisations”. This will mean “underperformance in one or more organisations can be balanced against over-performance in other organisations” and have “flexibility to vary the respective contributions of individual organisations to things like the system risk reserve”.
• It will “effectively abolish the annual transactional, contractual, purchaser/provider negotiations”.
• However, the document says a system control total is “not [an] exemption from the oversight regimes of NHS Englanf and NHS Improvement – or from normal business rules, system reserve requirements and the like”.
• It will mean “any individual [regulatory] interventions required taking place in partnership with the ACS leadership”.
• Each will receive a “devolved transformation funding package”. The funding will not be released until each ACS confirms “who is accountable for delivering value for money” and how it will manage financial and outcome oversight.
• ACSs are expected to “free up local administrative costs” from contracting, to “reinvest” elsewhere, while NHS England and NHS Improvement will “redeploy or embed attributable [central] staff and related funding”.

ACSs will be required to:

• Meet clear targets for priorities including cancer, urgent and emergency care, primary care and mental health.
• They are required only to “strive to deliver” the elective referral to treatment target, although there should be “no significant deterioration in waiting list size”, according to the draft document.
• “Lead nationally on a specific opportunity for system-wide efficiency” agreed with NHS England, such as consolidating back office.
• Establish “rigorous…population health management capabilities” that can improve prevention, patient self-management and reduce unwarranted variation, either doing this themselves or hiring “third party experts”.
• Show “clear mechanisms” to protect patient choice of where they receive elected care.

The memorandum is not clear about how the ACSs will be governed. There must be an “effective collective decision making and governance structure”, but states that an ACS is “not a replacement for individual accountability of boards”.

There will be a quarterly review of ACSs’ progress by national and local teams and NHS England or NHS Improvement will appoint a “lead regional director” for each system.

NHS England was approached for comment.