Accountable care is about more than just contractual arrangements, it is also about achieving coordinated care and delivering the outcomes that matter to patients. By Moira Fraser
It is clear that Accountable Care Systems are the current direction of travel in the NHS. What, then, does this mean for cancer care? The experience of NHS cancer services in recent years are testament to the challenges that can come with changes to the commissioning and delivery of cancer care and support.
Macmillan found that the 2012 Health and Social Care Act reforms led to disjointed care across the cancer pathway and confusion about commissioning responsibilities.
Given the ongoing fragmentation of cancer care, there needs to be a fundamental shift in the way in which care and support is commissioned and delivered to patients
Change is badly needed. Not only are there quality and efficiency considerations, but the integration of care is also one of the strongest predictors of overall satisfaction with cancer care in England. As more people survive cancer, and as the complexity of their treatment increases, so too will the need for better coordination.
This is even more important when seven out of 10 people with cancer (70 per cent) are also affected by one or more other serious conditions.
Given the ongoing fragmentation of cancer care, there needs to be a fundamental shift in the way in which care and support is commissioned and delivered to patients.
However, with much of the focus on the organisational form that ACSs and other emerging models will take, we risk losing sight of the fundamentals of integrated care designed in partnership with patients and health care professionals.
Accountable cancer care?
We know that emerging ACSs are defining their populations by geography rather than condition, which means that cancer patients will fall under their remit. However, we also know that a shift towards accountable care is being considered for cancer specifically.
The National Cancer Vanguard is currently piloting an accountable clinical network model for cancer and, since April 2017, has started trialling “delegated financial responsibilities” for the three geographical areas it covers. The aim of the pilot is to improve quality and reduce the fragmentation of the cancer pathway.
NHS England has also set out the intention that if this model is successful, the 16 Cancer Alliances may follow a similar path.
We still do not know if these initiatives will address the fragmentation that arose from previous reforms. However, we believe that now is the right time to examine both the emerging ACSs and the future role of Alliances from the perspective of cancer patients.
Thinking it through
In our new report, Thinking it Through, we do not debate the pros or cons of the transition towards ACSs, but instead question if they can be about more than changes in organisational form. To help our thinking we examined some international research, which breaks down accountable care into its constituent parts.
This “maturity progression framework” developed by the WISH accountable care forum in 2013 shows that making the transition to an accountable care model is complex, time consuming and involves a number of different steps and stages along the way.
However, more importantly from our point of view, it illustrates that accountable care is about more than just contractual arrangements. It is also about achieving coordinated care and delivering the outcomes that matter to patients.
To add further weight to this research we also considered the views of leaders in cancer care as well as learning from our involvement in complex system redesign partnerships. This led us to conclude that while the transition to ACSs will be complex and lengthy, the emerging accountable care structures should consider:
- Our experience from the Improving Cancer Journey Programme in Glasgow that interagency, personalised, and integrated care can be achieved without changes in organisational form;
- To achieve sustainable and meaningful change, patients, communities and healthcare professionals must be involved in system redesign from the outset and throughout the process.
The role of Cancer Alliances
From a cancer perspective, the large “footprints” of the 16 Cancer Alliances and the National Cancer Vanguard mean that a number of ACSs and Sustainability and Transformation Partnerships will sit in their geographical areas.
Alliances must drive forward improvements in partnership with patients and wider stakeholders
This means that Cancer Alliances will be working in a complex care and support landscape, and must make sure the transformations envisaged in the Cancer Strategy for England are realised.
The final conclusion of our report is that developing an accountable care model for a cancer population alone is not something Cancer Alliances should be focusing on at this time.
Given the complexities involved in identifying the budget and contract value for the cancer pathway in addition to the challenges of navigating governance and approval processes, we believe that Cancer Alliances’ time and energy could be better spent.
The National Cancer Vanguard’s experience of working with ACSs and STPs will establish the feasibility of an accountable care model for cancer. This should not be the job of Cancer Alliances.
Right now, Alliances have an essential and urgent role in driving forward improvements in cancer care and support across the pathway, from early diagnosis to living with and beyond cancer. They too must do this in partnership with patients and wider stakeholders and nothing should detract from this vital task.