The accountable lead provider: making integrated care a reality?

The current exam question for commissioners charged with ensuring the sustainability of the NHS is 'how can we make sure the NHS delivers integrated and sustainable services?', or as patients and their carers are more likely to describe it – 'who will make sure that we get properly joined-up care that will meet our needs going forwards?'

Providing integrated or joined-up care is an important challenge. However, it is not the only challenge and if effective co-ordination of care is to play a major role in sustaining the NHS, commissioners will also have to find ways to address other critical concerns about the provision of care, particularly for frail and vulnerable people. The challenges facing commissioners include:

First, there is a need to work out how to commission care that is holistic – focused on the person not the condition, carers as well as patients, and taking full account of physical, mental and social care needs.

Second, commissioners need to be able to procure care that brings about a transformation in service delivery, ensuring that services are provided as close to home as possible, based on shared decision-making between patients and clinicians, and with specialists providing support to this community-based service.

This will require the provision of specialist ambulatory care in the community, using multidiscipinary teams that work together for the benefit of patient and carer, free from organisational barriers and silos.

Third, and most importantly, commissioners need to find ways to secure accountable care, that is services delivered by a provider who is prepared to be accountable for the whole programme of care, both in terms of cost and quality.

On the face of it, this should all be straightforward – if accountable, integrated and transformed care is what you as a commissioner want (on behalf of your public, patient and carers) – then that is what you should buy!

However, as is so often the case, things are not that simple in practice. How can you buy accountable integrated care, for say 'the health of the frail elderly of Norfolk' or 'the musculoskeletal health of Bedfordshire' or 'the respiratory health of Oxfordshire'?

One answer to this conundrum is for bold commissioners to use an accountable lead provider approach, whereby the whole health care budget for a particular care group or population is used as the basis for seeking, possibly via open competitive tender, a provider who is willing and able to deliver an integrated set of services to meet the needs of that group or population.

The practicalities of taking such an approach to commissioning was the subject of a recent seminar held at the Nuffield Trust – The accountable lead provider: a new force for innovation in commissioning integrated care.

At the seminar, I argued that the NHS needs to be able to commission a new kind of provider that can deliver high value, accountable and integrated care.

An 'accountable lead provider' does not necessarily have to deliver the whole pathway of care, but they do have to be prepared to be accountable for the delivery of high quality services that are integrated, community-based where possible, and assuring high value across the whole pathway.

Subsequent discussion at the seminar explored the importance of being able to describe and price the elements of such an accountable pathway of care (for sub-contracts will be needed with the different providers involved), and support local clinicians and managers wishing to bring about what may be unwelcome or uncomfortable change.

Other topics explored included; the need for sophisticated support for new clinical commissioners wanting to use an accountable lead provider approach, consideration of how to do this alongside partners in social care and the third sector, careful exploration of how to ensure integrated care across pathways whilst avoiding challenge for being anti-competitive, and not assuring appropriate patient choice.

Professor Paul Corrigan and I have explored these and other issues associated with the accountable lead provider model of commissioning in a paper: The accountable lead provider: developing a powerful disruptive innovator to create integrated and accountable programmes of care, citing examples both from within the NHS and other sectors.

We do not claim that this is the only model available to commissioners to meet the unprecedented challenges facing the NHS, but do suggest that it is worthy of serious consideration. There are a number of case studies of accountable lead provider models in the NHS published on the Right Care web site.

The success of these pioneers will be measured by the extent to which they are able to bring about new forms of care that are well co-ordinated for patients and carers, based largely in the community, and assuring proper value for commissioners.

This will require attention to both the quality and cost across the pathway and it is likely to need a strong lead provider who can challenge the status quo and provide a new model of integrated and accountable care.

Dr Steven Laitner is National Clinical Lead for Shared Decision Making at the Department of Health. Please note that the views expressed in guest blogs on the Nuffield Trust website are the authors’ own.