What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

This is the first of two newsletters on what happens next for sustainability and transformation plans. This one covers accelerating some areas to new accountable care structures, and which places are involved in this. The second, next week, will cover: moving towards Greater Manchester-style delegation and resourcing, next steps for the other STPs, and implementation of the plans.

From STPs to accountable care

It’s finally arrived. After three years dropping unsubtle hints about moving ”the commissioner/provider split… along the demand/supply continuum”, Simon Stevens has finally spat it out and said he “will for the first time since 1990 effectively end the purchaser/provider split”. (HSJ readers will recall the commissioner-in-chief told us in December, with only a sliver more nuance, that STPs would become “organisational units… capable of combining the purchaser and provider, the commissioning and provider function”).

To make this happen, the aim is to fast track up to 10 STPs into new “accountable care” arrangements during 2017-18, ideally as quickly as within six-nine months.

It means these STPs will now become A Thing – more than just a plan. The only difficulty is, what is that Thing? Putting it another way, what comes after today’s purchaser/provider split?

The intention from the centre is that accelerating, supporting and prodding a handful of areas in the right direction will create models and inspiration for others to follow

The leaders of those areas lined up to take part certainly don’t have a clear or fixed idea - neither “accountable care organisations” nor “accountable care systems” have neat definitions or off-the-shelf models. These STPs will need to discover what accountable care means in England and shape it out of existing independent organisations. Those organisations might well object - there is a lot of disquiet about giving STPs and their leaders extra powers.

The intention from the centre is that accelerating, supporting and prodding a handful of areas in the right direction will create models and inspiration for others to follow.

Two models

Without prejudice to what will be extreme structural messiness for the next few years, the models on the table for STPs’ next steps can be grouped into two basic classifications.

The first is the accountable care system. This is less of a leap for most STPs and involves less of the difficulties, including procurement, which comes with contracting. All NHS organisations in an area – commissioners and providers – sign up to a formal agreement to work as a system.

There is open book collective management of the total budget and costs – see the recent agreement in Dorset, for example. There may be a single leader spanning both commissioner and provider, as with Devon’s STP lead Angela Pedder, and it helps a lot if they (like Angela) have authority and respect on the patch.

It’s unclear whether and how these individuals hold much formal, legal authority: while groups of CCGs or providers can share a chief officer, there are no cases of a shared chief executive crossing the divide and I suspect it’s illegal. ACSs risk looking like an NHS group hug, or stitch-up.

Although ACS arrangements retain existing organisations, and rely on soft power and collective will, the commissioner/provider split is undermined or at least bridged where there are senior roles and functions straddling both. As an illustration, David Williams, our integration expert, wrote about a proposed ACS in Berkshire last March.

The second model, the accountable care organisation, looks more like ACOs in the US (where this term comes from), and closer to what the new care models programme has been pursuing. Providers come together and, although there are several different ways of approaching it, create a formal partnership or entity (TUPE is likely to kick in).

This has responsibility for its population’s health, plus organising and providing the large majority of its care. This is a much bigger leap for virtually all STPs. Most have more than one large provider and it is hard to envisage them all forming a close-knit ACO – not to mention winning the required buy-in from general practice.

Strictly speaking an ACO is a provider or network of providers – it still needs to be contracted by a purchaser/commissioner. The ACO has a capitation budget, probably holds long term contracts, and makes most of the decisions about how care is coordinated for its population – so in turn the purchaser role changes a lot. The favoured description is becoming a “strategic” commissioner or system manager, maybe “thinner” – ie with fewer people – and generally covering a much larger area. This commissioner role means a significant step back for CCGs, but may be a relatively neat evolution where the STP lead is a commissioner, the CCG area is very large, and/or where CCGs are now joining management across a patch, like in several parts of London or around Bristol.

Others envisage CCGs shutting up shop more comprehensively and the contractor/commissioner function being held centrally, a bit like the delegation/devolution agreement between NHS England and Greater Manchester.

Hybrid models

Simon Stevens has publicly encouraged two STPs down the route of these types of models over the past year, Frimley Health and north central London. The former appears to be still on track, but the latter has butted up against the presence of multiple proud and independent foundation trusts in its patch.

They don’t want to unite as one ACO, and the area seems to be out of the running for now. Frimley is unique in two ways: having built an STP to match its catchment, and being led by HSJ’s Top Chief Executive. Others that might aim for it include south and mid Essex – where Clare Panniker is joint chief of the three acute FTs – and Bedfordshire, Luton and Milton Keynes, which is exploring but hasn’t yet pinned down joint trust leadership. 

One of the reasons structures will stay very messy in the next few years is that plenty of the STPs being teed up to lead the way don’t envisage becoming one of these models exclusively, but a mixture of the two.

For example, Greater Manchester has an ACS-style partnership of commissioners and providers, but it will also look to contract with aspiring ACOs in Salford and Stockport. Similarly for Lancashire an ACO covering the whole large patch, with several large providers, seems unlikely. But it could (as it is exploring) create a system that contracts with various ACOs within it. One of its patches, Morecambe Bay, seems well placed to take on that role, having explored provider integration and accountable care as a vanguard and before.

What seems a plausible path for many STPs – not only those singled out for acceleration this month – is to move to something along the lines of an ACS, then continue working on a more permanent arrangement involving an ACO or a network of ACOs. Smaller ACOs can more easily match to existing trusts, CCGs or council patches. Devon is currently making progress with a whole system agreement and a leader bridging purchaser and provider, but envisages moving to a strategic commissioner contracting with several local ACOs. This is why STPs are best seen as incubators of the future shape of the NHS rather than an imprint of it.

Which STPs will be involved?

Nothing is confirmed but I believe these areas, and a few others, are in the mix to take part: Greater Manchester; Devon; Lancashire; Frimley Health; Luton, Bedfordshire and Milton Keynes; Dorset; Northumbria, Tyne and Wear; Essex; South Yorkshire; and perhaps Birmingham and Solihull, now under new leadership.