From clinical commissioning to contracting for outcomes: prerequisites and facilitators to embed Accountable Care Organizations within the National Health Service in England

Abstract

Background: The 'Five Year Forward View' encouraged the NHS to innovate from bottom up and introduce new models of care that upgrade the role of prevention and public health and overcome the fragmentation between primary and secondary care, and between health and social care. Fifty vanguard projects were designated within the New Models of Care Programme, the majority categorized as Primary and Acute Care Systems (PACS), Multispecialty Community Providers (MCPs), Enhanced Health in Care Homes (EHCHs) and Acute Care collaborations (ACCs). Their impact is currently undergoing evaluation. A common aim of the new models of care programmes, similar to the Accountable Care Organization (ACO) movement, is to reward outcomes rather than activity. Yet, the prerequisites and facilitators to embed such programmes within the NHS, and the implications for commissioners of services, have so far not been well articulated. This study seeks to address this gap. Methods: A mixed-method approach combining document analysis and interviews with key informants is being used, approaching a group of clinical commissioning executives in the NHS. We will elicit their assumptions and experiences of new models of care, synthesize their feedback and discuss the resulting programme theory. Specifically, we will aim to elicit (i) current experiences and views of PACS, MCP, EHCH and ACC models, (ii) assess the fit of current contractual and procurement processes to support such models, (iii) investigate the capability to devise/utilise outcome indicators to guide contract implementation and (iv) gauge wider factors supporting or hindering the introduction of outcomes-based contracts (such as organizational cultures and personal relationships). Interviews will be enriched by analysis of supportive documentation. Preliminary results: Two issues need to be considered: First, innovations in commissioning and contracting to support integrated care preceded the Five Year Forward View (FYFV). In fact, since the 1980s various policies focused on internal markets and GP fundholding with major implications for the commissioning of services. Secondly, since the introduction of new models of care the financial pressures on the NHS have grown and various regulatory changes have been introduced by NHS England and the Care Quality Commission. These two issues impact on the views of commissioners to embrace the transformational changes set out in the Five Year Forward Year. Further preliminary results suggest that clearly specified population segments are favored over population based contract, partly because clinicians are more likely to be engaged if they feel their current responsibilities allows them to 'deliver' on the contract. However, this undermines the ambition of the new models of care programme to support the full vision of Accountable Care Organizations. In its core, implementing the FYFV and setting up ACOs requires new working relationships between commissioners and providers. Ongoing analysis will further elicit the programme theory underlying the implementation of outcomesbased contracts and identify steps to overcome existing challenges. Implications: Multiple challenges currently impede the design of outcomes-based contracts to implement new models of care. These challenges can be overcome, however, require a different relationship between commissioners and providers, supported by a shared understanding of outcomes frameworks, indicators, and contractual processes.