As mentioned on other pages, NHS England (NHSE) has divided the English NHS into 44 local health systems (‘footprints’), now described as Sustainability and Transformation Partnerships (ST Partnerships). NHSE expects these Partnerships to evolve into what were initially called Accountable Care Systems (ACSs) but, from February 2018, have been renamed as Integrated Care Systems (ICS) – perhaps because the term ‘accountable care’ had become rather toxic.
Although similar to ACSs, ICSs are not exactly the same: new guidance from NHSE, for example, suggests that some financial arrangements will be different. But it still seems to be the case that some, if not all, ICSs will be encouraged to become Accountable Care Organisations (ACOs) over time. Notably, the NHSE guidance makes no reference to ACOs, currently the subject of two judicial reviews and a public consultation in response to widespread concern from the public and bodies like the House of Commons Health Select Committee.
What were Accountable Care Systems?
An Accountable Care System was an evolved version of a ST Partnership, with responsibility for the health and resources for a defined population. An ACS differed from an ACO, partly because existing commissioning contracts remained in place. Commissioners, together with a network of providers across different services, entered into an alliance agreement and committed to managing resources together, along with agreeing governance arrangements and how to share risk and gain.
In return for providing ‘joined up, better coordinated care’, it was claimed that ACSs would have more control over the operation of the health system in their area. In reality, they provided a means by which national bodies (the Treasury, the Department of Health, for example) could assert more control, especial with regard to finances and performance.
Organisations within ACSs needed to share their workforce and facilities “where appropriate”, and create an “effective collective decision making and governance structure” – not easy, given that an ACS couldn’t replace the individual accountability of the organisations within it.
NHSE’s ambition was for ACSs to cover half the population of England by 2020, something it acknowledged would be a complicated transition, requiring a staged implementation.
First wave of ACSs (now ICSs)
By June 2017, Jeremy Hunt had announced eight ‘shadow’ ACSs, due to be formally designated for 2018-19. These were Frimley Health (including Slough, Surrey Heath and Aldershot), South Yorkshire & Bassetlaw (covering Barnsley, Bassetlew, Doncaster, Rotherham, and Sheffield), Nottinghamshire (with an early focus on Greater Nottingham and Rushcliffe), Blackpool & Fylde Coast (with the potential to spread to other parts of the Lancashire and South Cumbria at a later stage), Dorset, Luton (with Milton Keynes and Bedfordshire), Berkshire West (covering Reading, Newbury and Wokingham), Buckinghamshire.
These shadow ACSs agreed, in principle, a draft Memorandum of Understanding (MOU) with NHSE, signing them up to
- finding ways to control the uptake of services (or “more assertively moderating demand growth”);
- meeting quality targets;
- setting up appropriate governance, and
- accepting significant changes to how finances are controlled.
Each individual organisation within an ACS must remain accountable for remaining within the ‘financial control total’ set for them by NHSE and NHS Improvement to ensure that that any financial deficit providers had was reduced to zero. . Agreeing to deliver a control total was a condition of access to the Sustainability and Transformation Fund.
The introduction of financial control totals for all NHS providers in 2016/17 (regardless of whether they were in deficit or not) meant a dramatic extension of central control. These controls govern how an organisation uses its own reserves, and enforce a range of other conditions from the centre (ie NHSE and NHS Improvement) – for example, they dictate how to manage annual leave, short-term sick leave as well as issues of financial management.
But in addition, in order to facilitate the pooling of resources across providers within the ACS, these providers must also be accountable as a collective for achieving a ‘system control total’ (equal to the sum of the control totals of all organisations within the system). The MOU acknowledges that this new approach to financial control will “inevitably be bumpy in terms of its impact on the financial position of individual organisations”.
As some have suggested for ACOs, new systems like ACSs may mean substantial changes to the role of Clinical Commissioning Groups (CCGs). It’s possible that CCGs will remain responsible for
- ensuring that ACSs are commissioned in order to provide maximum value;
- setting the required population-level outcomes; and
- holding ACSs to account for delivery.
But providers (NHS or private) could take on the delivery of, or contracting for, all NHS and local authority funded health and care services. Providers could also be responsible for ‘integrating’ primary, community and hospital services. Not only this, as an ACS developed, existing contracts could be amended to require providers to agree to the transfer of the supervision of their contract to another provider – or to the system’s Care Integrator (potentially a private company) in place of the CCG.
From February 2018 the eight existing ‘shadow’ ACSs (now ICSs) will face new regulatory oversight and financial arrangements.
Integrated Care Systems
New planning guidance from NHSE and NHS Improvement (NHSI) published in February 2018 reinforced the move towards what it calls ‘system working’ through ST Partnerships and the voluntary roll-out of ICSs over the year 2018-19. It described ICSs as those systems
in which commissioners and NHS providers, working closely with GP networks, local authorities and other partners, agree to take shared responsibility (in ways that are consistent with their individual legal obligations) for how they operate their collective resources for the benefit of local populations.
The guidance clarified that it is now using the term ICS as a collective term for existing ‘shadow’ ACSs and the devolved health and care systems in Greater Manchester and Surrey Heartlands.
ICSs are expected to focus on
- managing population health (e.g. improving the health of a defined group, rather than focusing on individuals’ health needs),
- delivering more care through redesigned community and home-based services,
- taking collective responsibility for financial and operational performance, and
- ‘more robust’ arrangements between organisations within the system.
Instead of operating as separate bodies, each organisation within an ICS should sign up to a plan for operating as a single system that incorporates relevant CCGs and providers, and establishes a common approach to things like income, expenditure, workforce, and activities. This focus on an overall system rather than individual organisations within a system allows NHSE and NHSI greater oversight or control.
Each shadow ICS is expected to produce a plan that will deliver its ‘system control total’, (“the aggregate required income and expenditure position for providers and CCGs within the system” as decided by NHSE and NHSI). Failure to draw up appropriate plans or comply with a system control total will mean loss of access to funding. Notably, organisations within an ICS will be responsible among themselves for resolving any disputes arising from the ‘system control total’.
The King’s Fund has rather muddied the waters by introducing a sub-category – Integrated Care Partnerships (ICPs). They use the term ICS to refer to a body evolving from an ST Partnership in which various organisations come together voluntarily to plan and commission services across a geographical footprint. Within that area there will be a number of ICPs, each comprised of a range of organisations that will deliver services to more localised areas.