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All STPs will become 'accountable care systems', NHS England announces

All health and social care organisations that drew up plans to overhaul care in England will eventually become accountable care systems, according to new plans released by NHS England.

Regional organisations that created sustainability and transformation plans (STPs) will ‘evolve’ into accountable care systems (ACSs), with some acquiring the status as early as April this year. 

NHS England’s Five Year Forward View delivery plan has said that hospital trusts, CCGs and local authorities in the new ACSs will ‘take on clear collective responsibility for resources and population health’.

However, the report notes that CCGs alone will be responsible for improving emergency admission rates, which will be measured and managed on an STP or ACS level from April. 

To do this, NHS England has committed to working with ‘upper quartile higher referring GP practices and CCGs’ to standardise the ‘clinical appropriateness’ of hospital referrals, using CCG data and 'a new tool from NHS Digital'. 

Simon Stevens, head of NHS England, announced at a Parliamentary Accounts Committee meeting last month that between six and ten STP areas would be launching as so-called accountable care organisations (ACOs).

However, the delivery plan says that ACOs are the next step after becoming an ACS, with some becoming an accountable care organisation 'in time'.

In return for becoming an ACS, NHS England has promised the organisations ‘more control and freedom’ over their regional health system including receiving devolved national GP Forward View, mental health and cancer funding from 2018.

The healthcare systems will be set up in stages with the first to be implemented from April this year.

NHS England noted nine STP areas that are ‘likely candidates’ to become the first ACSs, including:

  • Frimley Health
  • Greater Manchester
  • South Yorkshire & Bassetlaw
  • Northumberland
  • Nottinghamshire, with an early focus on Greater Nottingham and the southern part of the STP
  • Blackpool & Fylde Coast, with the potential to spread to other parts of the Lancashire and South Cumbria STP at a later stage.
  • Dorset
  • Luton, with Milton Keynes and Bedfordshire
  • West Berkshire

The delivery plan added that areas applying for ACS status should have ‘successful vanguards, ‘devolution’ areas, and STPs that have been working towards the ACS goal’.

Readers' comments (6)

  • Vinci Ho

    No matter how they play with reorganisation, the reality is not going to change in the hands of this government:

    MISSION IMPOSSIBLE?
    The task for NHS providers in 2017/18
    Summary
    https://www.nhsproviders.org/mission-impossible/summary

    The 2017 Budget on 8 March confirmed that, while there was extra money for social care and a small amount of extra capital funding for the NHS, there would be no extra revenue funding for the NHS in 2017/18, with the new nancial year starting on 1 April 2017.
    Analysis by NHS Providers predicts that, without realism, exibility and support, it will be impossible for the NHS hospital, ambulance, community and mental health trusts who account for more than 63%1 of NHS spend to deliver all that they are being asked for in 2017/18.
    What NHS trusts need to deliver in 2017/18 ?-
    2017/18 NHS trust delivery requirements are set out in the NHS 2017/19 planning guidance. They can be summarised as:
    * absorb a forecast 5.2% demand and cost increase
    * deliver the required NHS constitutional performance targets, for example the 95% A&E 
four hour standard, the 18 week elective surgery standard and the cancer targets
    * eliminate the provider sector nancial de cit and deliver a minimum zero aggregate provider sector nancial balance
    * all within the NHS funding allocation, which will increase in 2017/18 by a much lower amount than in 2016/17. 
Why the 2017/18 delivery requirement 
is currently impossible to deliver 
While individual NHS trusts may be able to meet all their delivery requirements, and individual requirements can be met at a sector level, the aggregate 2017/18 provider sector task is currently undeliverable for the following six reasons: 

    * 1  NHS trusts will receive a smaller funding increase in 2017/18: provider NHS funding increases are dropping from 4% in 2016/17 to 2.6% in 2017/18 (see section 2).2 

    * 2  However, demand and cost is predicted to rise by 5.2% in 2017/18, double the 2017/18 NHS provider funding increase of 2.6%. 

    * 3  Evidence from the last decade indicates it is impossible for NHS provider efficiency savings, which average between 1 and 2% per year, to close this gap, which would be required to just maintain existing performance. 

    * 4  Key performance targets are already being missed and achievement of the performance targets in 2017/18 will require a signi cant improvement and extra investment. For example: 

    Performance against the key 95% A&E standard in the 12 months to January 2017 was running, on average, at 88.9%. NHS Providers estimate it would cost an extra £400-600 million to recover performance to the required level across the year.

    Performance against the key 92% 18-week elective surgery target is running at 89.9%. NHS Providers estimate it would cost a minimum estimated £2.0-2.5bn to recover performance to the required level.
    * 5  The NHS provider sector will enter 2017/18 with a likely de cit of between £800-900m and therefore needs to improve its nancial performance by this amount to eliminate the de cit and achieve the required balance. 

    * 6  NHS trusts are required to deliver a new set of extra commitments from the recent cancer and mental health taskforces which NHS Providers estimates will cost between £150 and 200 million. 

    In short, the 2017/18 funding increase, together with best case scenario provider efficiencies , does not even cover the predicted cost and demand increases in 2017/18, which is required to just maintain existing performance levels. NHS Providers estimates it would cost a minimum further £2.4-3.1 billion, which the NHS cannot afford, to recover the performance standards to required levels. There are two further £800-900 million and £150-200 million pressures to eliminate the provider sector deficit and meet extra new commitments. If NHS trusts could not deliver NHS performance standards on a 4% funding increase for trusts in 2016/17, there is no evidence to suggest they can deliver them on a 2.6% funding increase in 2017/18.
    The 2017 budget announcements of £2 billion for extra social care, £100 million capital for extra GP front door triage in A&E Departments and £325 million capital for the most advanced sustainability and transformation plan (STP) footprints were welcome. However, they are unlikely to make a significant difference to this underlying position. The impact of extra social care support on NHS performance in 2017/18 is uncertain given that there are no “must benefit the NHS conditions” attached to the new funding. Extra capital of £425 million is marginal in the context of an estimated £2.4 billion a year required for STPs and a forecast maintenance backlog of £5.8 billion.
    Impact on patients and staff
    Patients will be impacted if NHS trusts are unable to meet all their delivery requirements. Depending on what is prioritised, this impact could, on current performance trajectory, mean an estimated 1.8 million patients having to wait more than 4 hours for A&E treatment and an estimated 100,000 patients waiting longer for elective surgery than they should do – 40% and 150% increases on the respective levels this year.Trying to meet performance targets on inadequate funding levels also places an unfair and unsustainable burden on NHS staff.
    NHS Providers is particularly concerned by the impact on patient safety of current bed occupancy levels in both acute and mental health settings. Events in January 2017 showed that, in a number of local systems, we are now putting patient safety at unacceptable levels of risk. We argue that in the re-prioritisation the NHS must now undertake, addressing this risk should be a key priority.




    NHS Providers shares the recent judgement of the chief inspector of hospitals
that “the scale of the challenge that hospitals are now facing is unprecedented – rising demand coupled with economic pressures are creating di cult-to-manage situations that are putting patient care at risk”.This applies to the entire provider sector.
    What next – the options
    NHS trust leaders are strongly committed to providing the best possible care for patients, meeting their NHS constitutional performance standards and achieving nancial balance, including an appropriate degree of performance, productivity and nancial stretch. Their strong and clear preference is for the NHS to be funded at a level that enables the average trust to deliver that aggregate task. However, in the absence of adequate funding to achieve this and with less than a fortnight till the start of the new nancial year, NHS Providers believes that the NHS now has to make some rapid, difficult, choices.
    There are two broad approaches.
    One is to act as though delivery of the requirements is still achievable. This risks setting an impossible task for trusts, misleading the public, preventing the NHS from planning to maximise patient benefit from the resource spent and placing an unsustainable burden on frontline staff.
    The second is to fully develop the emerging approach being adopted by the NHS arm’s length bodies, who have recently indicated that the 95% A&E standard will not be deliverable across the year.The NHS leadership needs to recognise that delivery of all the current requirements in aggregate is no longer possible and they need to set more realistic targets, with appropriate flexibility:
    * The NHS England mandate and the new NHS delivery plan, due at the end of March, need to set out what can be realistically delivered for 2017/18 in relation to each priority. 

    * Building on work already undertaken, the NHS should carry out an urgent exercise to examine whether, by the end of quarter 1, money could be reallocated from non- frontline care (commissioning costs, and further reductions to administration budgets from the Department of Health and its arm’s length bodies),to frontline care. 

    * Frontline and central NHS leaders need to work together to identify what support and investment is required to enable trusts to make signi cant progress in reducing the unwarranted variation in performance between trusts that has been identified in several recent reviews. 
NHS trusts will do everything they can to deliver what they are asked but they will need realism, support and exibility from NHS political and system leaders.

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  • Vinci Ho

    Agent Hunt , well done, you have many lives to die 10,000 times to pay for this desolation.
    This message will self destruct in 5 seconds.....

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  • Vinci Ho

    Everything to do with delivering health and social care is going under the jurisdiction of ACS . ACO, the actual leading organisation, is to be formed in each region.
    The real function of ACS is clear in its role on finances:

    Next steps on the NHS Five Year Forward View
    NHS England published on 31/3/2017:
    Page 53:

    The Government’s Mandate to the NHS for 2017/18 requires it to “ensure overall financial balance in the NHS” with “all parts of the system – commissioners and providers – meeting their control totals”.57 This is going to require tough decisions and decisive action.
    Financial performance has improved across the NHS over the past year(2016/2017).Commissioners have generated an £800 million managed underspend, and most trusts are on track to meet their control totals. But as the NHS goes in to the next two years of intensified financial challenge, financial success will require managing a number of important risks and dependencies, including reducing both NHS-related and social care-related blocked acute beds as set out in the chapter two; the level of emergency admissions growth; effective deployment of available capital to unleash trust efficiencies; and workforce availability in key staff groups. In 2017/18, funding has been allocated up-front to frontline services so there is no substantial national ‘bail out’ fund that can cover off poor financial control by individual trust boards or CCG governing bodies. The importance of individual trusts and CCGs meeting their financial control totals and sticking to their budgets is critical. So in 2017/18:
    o Each provider trust and CCG will again be set a financial control total (which may by prior agreement be flexed between organisations within an STP or ACS system control total) and which they must meet.
    o 70% of the national Sustainability and Transformation Fund will again be tied to delivery against trust-specific financial control totals.
    o Provider trusts not agreeing control totals will lose their exemption from the default fining regime in the NHS standard contract, and CCGs missing their financial goals will lose access to the CCG Quality Premium. From August 2017 CQC will begin incorporating trust efficiency in their inspection regime based on a Use of Resources rating.
    o Trusts and CCGs missing their individual (or, where applicable, system) control totals may be placed in the Special Measures regime. CCGs in that status will be subject to legal directions and possible dissolution.
    o Some organisations and geographies have historically been substantially overspending their fair shares of NHS funding and their control totals, even taking account of access to the STF. In effect they have been living off bail-outs arbitrarily taken from other parts of the country or from services such as mental health. This is no longer affordable or desirable. So going into 2017/18 it is critical that those geographies that are significantly out of balance now confront the difficult choices they have to take. Where necessary this may mean explicitly scaling back spending on locally unaffordable services, so that they go in to the next two years with a viable and balanced income and expenditure plan, delivering locally the Government’s Mandate requirement for the NHS to balance its books.


    It is all about STP or ACS control total ( jargon again!!)

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  • Vinci Ho

    And there will Regional Directors(RDs):
    Page 16:-
    Aligned national programme management.
    To ensure complete alignment between NHS England and NHS Improvement in supporting and overseeing urgent implementation of the above actions, we have appointed a single national leader accountable to both NHS England and NHS Improvement. We will also bring together the work of NHS Improvement’s and NHS England’s national urgent and emergency care teams. From 1st April 2017 a single, named Regional Director drawn from either NHS Improvement or NHS England will hold to account both CCGs and trusts in each STP area for the delivery of the local urgent care plan. Each RD will therefore act with the delegated authority of both NHS Improvement and NHS England in respect of urgent and emergency care.

    History repeats itself , turning back the clock ????

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  • The challenges in secondary care are not because of GP admissions. If secondary care feels the admission is inappropriate they are free to send them home.

    The issues in secondary care are mostly due to a lack of beds, rocketing patient demand, more sick patients due to an older population with more co-morbidities and bed blocking due to the social care crisis.

    Devolved funding is just an excuse for NHS England to lay the blame for the next crisis on the CCGs/ACOs/GPs

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  • Is NHS England itself going to become an accountable organization ever, that is the question that we should be asking. Making everyone accountable to the primary cancerous tumour doesn't make much sense, does it?

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