Key challenges of shared risk and benefits of integrated care

The broader context in which risk shares are being agreed adds complexity to the process because local teams and organisations are wary of adverse or unknown financial implications. Both local government and NHS commissioners are under significant financial pressure.

This can make the risk share process combative rather than an opportunity to reach a shared understanding of vision and objectives for the local health and care system.

It is important that local systems should focus first on developing joint plans, and then on developing the risks and benefits share to support the implementation of those plans. Function should come before form: be clear about what needs to be achieved and how it will be achieved, and have a robust risk and benefits management approach. These aspects are essential to enabling organisations to work together to deliver integration.

Key challenges

• We are in a deficit – how can we convince our finance colleagues that this is the right thing to do? How can we sell this to the system decisionmakers and stakeholders? Open

  Potential solutions

  Be clear about the benefits and risks. Take a more bottom-up and evidence-based approach to demonstrate system benefits for all parties. Identify the common ground as outlined in the step-by-step development approach. Consider the potential benefits and be clear about what the real risks are in not achieving given targets. Local areas should triangulate the conversation so that it includes clinicians, project managers and finance stakeholders in order to ensure what is agreed works.

  Reference to ‘Building Blocks’

  2. Common purpose
  5. Trust and strong relationships

  How-to-steps

  1. Determine who are the relevant parties to be involved in the risk and benefits share.
  2. Establish any circumstances affecting what risks and benefits each organisation can take on and any factors preventing them from taking on certain elements of risk.
  6. Determine each organisation’s risk appetite and agree risk appetite at a system level.

• Why is it difficult to work across different organisations to develop and agree a risk and benefits share arrangement for programmes that focus on reduction of non-elective admissions? Open

  Potential solutions

  Joint plans to reduce non-elective admissions usually consist of many different projects, schemes and initiatives (e.g. rapid response, A&E front-door, integrated case management). This causes issues around attribution – which intervention contributes to the reduction – and who is responsible for it. It is difficult to attribute where the benefits share would lie. When non-elective admissions increase it is equally difficult to understand the causes. Is it an increase in demand? Is it the failure of the schemes – if so which one was not effective? How should we as a system pay for additional demand?

  Developing shared priorities, objectives and outcomes around target population or group (e.g. +75 population) is a more helpful approach in two ways – and is also good practice in accountable care systems. 1) It is much easier to develop a joint plan around the person or a population group – rather than a collection of services or professionals. 2) It provides a framework that addresses the root cause and takes into account needs, behaviour and assets. This helps local systems with prioritising schemes that better target outcomes but also makes it easier to identify where the risks and benefits lie – and who is responsible for it. This helps inform the initial agreement and on-going management arrangements.

  Reference to ‘Building Blocks’

  2. Common purpose

  How-to-steps

  3. Agree priorities and objectives of each party and the risks and benefits to achieving this individually.
  8. Identify target population for each project.

• What is expected in terms of local areas being asked to consider putting an appropriate portion of funds into a risk and benefits share agreement for contingency purposes? Open

  Potential solutions

  There is no suggested contingency due to the different needs and the risk appetite and tolerance of each local area – and the nature of the projects. The first step for each area is to determine what the joint area priorities are and the best method for achieving these goals. The second step is to determine what benefits and risks are associated with that method.

  From early evidence, nationally and internationally, the critical ingredients for successful collaborative working are bringing together system aims, pooling resources and sharing benefits and risks to achieve improved outcomes for the population and increase system benefits.

  Reference to ‘Building Blocks’

  3. Shared understanding
  4. Pragmatic governance

  How-to-steps

  4. Use information from step 3 to agree collective priorities and objectives.
  5. Agree collective net risks and potential benefits for achieving objectives.

• How do we know which risk and benefits to share for our joint programme of work (e.g. out-of-hospital services) when we don’t know what the baseline measure is? Open

  Potential solutions

  Local areas should understand and establish their baseline as a priority. It is important that system leaders and managers work collectively to map the benefits and risks from both a ‘bottom-up’ and ‘top-down’ direction – so that it is fully understood and can be managed appropriately.

  Reference to ‘Building Blocks’

  1. Transparency
  3. Shared understanding

  How-to-steps

  9. Agree baseline to which to measure performance.

• What happens if we need to make changes to our risk and benefits share arrangements once we’re ‘up and running’? Open

  Potential solutions

  All plans – no matter how well developed – will be challenged by the realities of execution. Key scenarios should be developed and agreement made on how to manage them. This needs to be reflected in the governance and management approach.

  The arrangement and agreement also need to be clear on what is fixed and what is variable. For example, Torbay in section 5.1: the risk and benefits share agreement is clear that variances occur, and should be dealt with through the agreed governance arrangements. They also agreed that the level of contributions from each party (and benefits to each party) will remain the same throughout the agreement – established using the initial baseline position. Trust, senior system leadership and pragmatic governance structure are key to making this work operationally on the ground.

  Reference to ‘Building Blocks’

  4. Pragmatic governance
  5. Trust and strong relationships

  How-to-steps

  2. Establish any circumstances affecting what risks and benefits each organisation can take on and any factors preventing them from taking on certain elements of risk
  7. Identify the extent to which each organisation can influence the risks and benefits. On this basis, agree how risks and rewards will be shared in principle
  10. Agree metrics for measuring performance