All systems go
Claire Ward examines the possible implications of Accountable CareÂ Systems on community pharmacy
In June, Simon Stevens, chief executive of NHS England, announced that there would be nine new accountable care organisations (ACOs) across the country as the NHS moves to a new phase of collaboration across health and social care.
For most people, especially the average independent pharmacist, an ACO may not seem very relevant, in fact most will not have heard of them â€“ yet. But the future could look very different if some of the ambitions can be achieved.
The new ACOs â€“ or Accountable Care Systems (ACSs) as they will be known in England â€“ will be trialled in nine areas across the country including Nottinghamshire and West Berkshire and build on the devolved power already given to the city of Manchester and now to Surrey County Council.
The model for ACOs has come primarily from the USA, though there are examples operating in New Zealand. In the US, it was based originally on legislation during Obamaâ€™s presidency, and, though primarily funded through private insurance systems, the role of the ACO is to bring together a range of authorities that can provide care by putting the patientâ€™s needs at the focus of everything. Payment is then made to the ACO by the insurance provider. ACOs also must meet quality measures and if they donâ€™t meet all of the quality measurers they donâ€™t receive all the funding.
Funding is based on a fixed sum for a defined population and the assumption is that there is an incentive for providers to keep people healthy, less reliant on interventions and also to invest in primary and community care to keep people out of expensive acute care. There are US examples showing some significant savings and reinvestment that allow ACOs to focus on those people who are the greatest users of services with the highest health and social care needs. However, there is also evidence to suggest that some have been unable to fund the care and treatment and have run up losses.
So the US model is not perfect. Indeed, they are not without their opponents both in the US and the UK. Some NHS campaigners believe that the introduction of accountable care systems will mean greater management of demand and that this will lead to fewer treatments being made available on the NHS.
Furthermore, they argue that the US model is primarily one that requires services to be provided within a fixed budget through managed demand and the pathways that patients are on, allowing savings to be made as profit for the private sector. As the ACSs are a partnership with private and public care, they see this as a way of undermining the NHS. Those who have opposed PFI are certainly of this view, seeing this as just another model of public private partnership where the greatest benefit is gained by the private sector.
Despite some opposition, itâ€™s clear that NHS England (NHSE) see the Sustainability and Transformation Plans, NHS Vanguard models and ACSs as collaborative provider models. Indeed, given the problems faced by the NHS and social care, and of course recognising that sometimes health is impacted by other problems such as housing, employment and other social factors, NHSE knows that it must do something different if it wants to improve patient care and be more cost effective in doing so.
In promoting ACSs, the NHSE launched a video from a project running in Weymouth to bring all health and social care professionals under one roof in a community health hub. From the patientâ€™s perspective it has joined up the silos and helped them to have a coordinator of care. The reality of collaboration is already here but of course it could be better.
Interestingly, there is no reference to a community pharmacist, but given the investment in pharmacists in GP surgeries, this may well be an inclusion in the future. If we assume that devolving power means local communities and organisations can do things differently, this may well be a great opportunity for pharmacy. We know that effective use of primary care and managing longterm conditions can keep more patients out of hospital. Yet there have been few opportunities to turn this into a widespread and greater use of pharmacy.
If ACSs have the potential to invest in new services for pharmacy because they recognise that, for example, patients with diabetes or COPD could be managed and supported with named clinical pharmacists based in either community pharmacy or local clinics, then this may be a way to improve care and reduce overall costs. Itâ€™s exactly the example that many ACOs in the US are already implementing though not exclusively with pharmacists.