Accountable care is a means to an end

Accountable care is on everyone’s lips: it already has its own curious identity, spoken of as either a panacea or a transatlantic plot for secret privatisation.

Some dismiss it as the latest fad, or are sceptical that it is even possible, or feel reluctant to embark on such a major change process when already daunted by financial and operational pressures.

The truth is that accountable care offers a genuine opportunity to look at population needs in health and care, and to direct the public pound in ways that maximise prevention, early diagnosis and intervention, and self care. 

Accountable care, when successfully implemented, makes better use of resources and cuts through wasteful duplication. It may well be the only game in town for health and care.

It can break down barriers between the NHS and local authorities; commissioners and providers; mental and physical health; NHS and social care; primary care and acute care, and bring third sector providers more into the mainstream—all for the advantage of patients who stand to benefit from better access to better joined up care. 

Accountable care, when successfully implemented, makes better use of resources and cuts through wasteful duplication. It may well be the only game in town for health and care.

But change is slow—and challenges are complex, individual motivation is complex and the objectives themselves are complex. There is a danger, too, that complexity is the only thing on which everyone agrees, which quickly turns it into a comfortable place to spend time.

From our respective work in supporting the development of accountable care, we have learned that getting started on this journey means setting aside technical, legal and conceptual complexity and looking honestly and collectively at where you are – and to chart a course forward from there.  

Here are our dos and don’ts – far from exhaustive, but in the spirit of collaboration, a starter for 10:

Do…

• Start at the start: what is your local case for change? Why are you trying to bring about accountable care? Find one thing that everyone can agree on – this needs to be meaningful (so not just “good patient care” but something like “care in the most appropriate setting”) and something people will actually put organisational weight behind. If there isn’t anything yet, you need to keep going until you find one thing that can act as a pivot.
• Remember that accountable care, or whatever name you choose to call it, is not an end in itself.  It is a means to an end: don’t lose track of your end.
• Get clinicians involved from the very start. They need to be at the heart of the initiative if it is to have the clinical knowledge, credibility and leadership necessary to succeed.
• Get everyone around the table very early on—don’t forget colleagues in other parts of the health and care system. You will need all the perspectives and voices to build a strong foundation. Allow people to be heard but ask them also to listen. Practice perspective taking and empathy. 

Pick one thing to do well and have the confidence to de-prioritise. No one can do everything at once, some things will have to wait.

• Allow the building of trust and relationships to take time. Invest this time. Experience shows that trust and strong relationships are the bedrock of any successful change programme. 
• Allow people to feel uncomfortable and challenged, address the feelings honestly and ameliorate them – if unaddressed, people’s fear will reemerge as intransigence.
• Acknowledge the complexity and the scale of the challenge, but also talk about what people think is possible. It might not sound exciting or glamorous at first, but it is more likely to be real and, ultimately, to be delivered.
• Pick one thing to do well and have the confidence to de-prioritise. No one can do everything at once, some things will have to wait. The key is having the confidence to make the choice.

Don’t…

• Be daunted by the legal and budgetary complexity, and don’t spend lots of early time on types of care models and legal forms of provider model. This can become a displacement activity that will distract you from answering the question about what you need and want to do.  Start instead with outcomes and behaviours.
• Think you have to fix everything today – the goals will move, the world will change – the test to apply is “do we think we are doing the right thing?”

Don’t be daunted by the legal and budgetary complexity, and don’t spend lots of early time on types of care models and legal forms of provider model

• Pretend that everyone agrees when they don’t – better to have an honest argument than to pretend everything is fine until time, money and energy have been invested in something that was never going to be allowed to succeed. Difficult conversations are central to making positive change happen.
• Forget to celebrate the small steps forward – this is hard work, it should feel difficult, every success is real, however small. Big change starts with one small step.

 Julia Simon is director, Thesis 11 and former NHS England head of commissioning policy; and Claire Kennedy is managing director, PPL