Can US health models fit the NHS?

What would the arrival of US-style accountable care organisations mean for GPs? Marina Soteriou reports.

New primary care models could be in the pipeline for England.

Kicking off a wide-ranging review of general practice last month, NHS England warned that healthcare models borrowed from US accountable care organisations (ACOs) such as Kaiser Permanente could be used to deliver NHS primary care.

But what are they and what do they mean for GPs?

ACOs

An ACO is a loosely-defined healthcare model that aims to promote integration, reduce costs and improve healthcare outcomes.

ACOs are led by a group of providers with a pooled budget, meaning primary and secondary care work together and share objectives.

Targets inevitably include reducing expensive hospital activity because ACOs cannot rely on government bailouts.

Adopting the ACO model would represent a shift away from activity-based payment systems such as the much-maligned Payment by Results, which health secretary Jeremy Hunt has already pledged to review.

The ACO model can mean financial risk is transferred to providers, a prospect few GPs would welcome.

Supporters of ACOs say this transfer ensures providers work together to stay in budget and work towards agreed outcomes.

For some ACOs, a proportion of central funding will depend on improving outcomes and meeting targets - similar to the quality premium that will be paid to successful CCGs.

Political support

There are signs from Whitehall that ACOs are something the government wants to introduce to the NHS.

Care and support minister Norman Lamb has said he is keen to support the implementation of different healthcare models that drive integration.

It could be argued that the NHS in England is halfway to having an ACO healthcare model.

Through CCGs, GP practices are already part of membership organisations that are accountable for all of the local population's health.

Part of the culture shift the government's recent NHS reforms were intended to create was for GPs to question how each of their decisions affected the whole CCG population, not just the patient sitting in front of them.

National Association of Primary Care chairman and Surrey GP Dr Charles Alessi argues that CCGs are already taking on a substantial financial risk, similar to an ACO model.

'CCGs have a limited financial envelope and the more they put into secondary care the less goes into primary care,' he says. 'We are there already.'

The NHS reforms also brought in the controversial quality premium, a £5-per-patient payment that will be made from 2014/15 to CCGs that boost patient outcomes and improve the quality of services.

The BMA bitterly opposed its introduction because it did not believe that funding should be held back from providers in this way.

GPs fear they will be pressured into cutting down on referrals to enable CCGs to stay in budget so that they can earn the quality premium.

These rationing fears will be exacerbated by the introduction of ACOs, the GPC warns, because there will be more pressure for practices to stay in budget as they could be forced to take on a greater financial risk.

Mr Hunt's plans to make GPs in England the named, accountable clinician for the frail elderly when leaving hospital also seem to be influenced by the work carried out by ACOs in the US, which hire case managers to coordinate the care of patients with complex conditions to prevent costly hospital admissions.

What is Kaiser Permanente?
  • Not-for-profit healthcare plan with more than 9.1 million members in the US, spread across nine states and the District of Columbia.
  • Tries to house primary and secondary care together.
  • Strong focus on evidence-based care, prevention and research.
  • Invests heavily in IT with an integrated electronic patient record.
  • Annual revenue roughly equivalent to one third of entire £100bn NHS budget.
  • Set up in 1945 to treat industrial workers, just three years before NHS began.

Why now?

The NHS is heading for a £30bn funding gap by 2020, NHS England warned last month.

An ageing population means demand for health services is increasing.

Mr Hunt has warned that GPs will need to take a more pro-active approach to the frail, elderly on their lists to create efficiencies across the whole of the NHS, because they are the people that use it most.

These so called 'frequent flyers' seem to be providing the impetus around the talk of ACOs being introduced to the NHS.

There is a cross-party consensus that services will need to be better integrated for these 'high-flyers' who often end up in hospital, because no alternative community service exists.

GPs have for years lived with the reality of funding not following patients out of expensive hospital settings.

Fans of ACOs say they can cut out inefficiencies and free up money for investment in primary care.

GPC deputy chairman Dr Richard Vautrey warns that integrated care can mean different things to different people.

'If this is just about cutting costs then ACOs will fail patients,' he says.

'We would need to see a lot more detail about what they really mean by an ACO before we could make a judgement about whether this would be helpful or just another bad idea imported from the US.'

Financial risk

Clinical chairman of Crawley CCG in West Sussex Dr Amit Bhargava says ACOs are the 'holy grail' for the delivery of care because they bring providers from secondary care together and can reduce duplication of services.

But implementing them will be difficult, he says. 'At the moment the risk of running out of money does not lie with practices. As a GP I would not want to take on the risk of the budget - if I have one patient with a severe trauma we could run out of money.

'We need to have some checks and balances in place.'

Commissioners should not be able to transfer all the financial risk to practices and other providers without safeguards to help ensure they make a profit, he says.

Reform

The government is unlikely to introduce ACOs to the NHS before the 2015 general election, so soon after the reforms that introduced CCGs.

But this will not stop ministers from looking to ACOs for further inspiration.

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