Creating and embedding risk and benefits sharing of integrated care

What are the building blocks?

From experiences with colleagues nationally and internationally, risk and benefits sharing works well when all stakeholders across the system, including commissioners, providers and patients, have demonstrated the following attributes:

  1. Transparency – clear baseline and performance measures can be tracked. This needs to be proactive and regular so that issues can be dealt with ‘in-flight’. There should be a minimum of a review every quarter. This is the mechanism that will enable stakeholders to know their latest risk and benefits position and help them follow the four attributes.
  2. Common purpose – ensure there is a clear common purpose concerning the intended outcomes for the local population and the ways in which services will be reshaped to meet those outcomes. The focus should be on system and individual outcomes. Please see How to … understand and measure impact.
  3. Build a shared understanding among leaders, staff, partners and service users. This is important in terms of the extent to which each partner can influence the risks and benefits identified. Partners should work together to achieve collaborative working.
  4. Clear and pragmatic governance arrangements concerning decision-making and accountability, with shared leadership at political and executive levels.
  5. Trust and strong relationships are essential – the personal chemistry between local leaders is as important as formal plans and strategies.

What are the key considerations at each level of the system?

Risks and benefits can be considered at a project, organisation and/or system level. It is for the organisations involved in developing risk and benefits share arrangements to agree at what level this should be done and how risk and reward should be apportioned between the parties involved.

The aim should be to move towards agreeing risk share at a system level to incentivise and drive the local system to deliver improved outcomes and results.

What are the routes to risk and benefits sharing?

There is a range of routes to sharing risks and benefits. The simplest are set out below.

Activity commissioned

A simple route to risk and benefits sharing is to allocate risk and reward on the basis of the activity that each organisation commissions in that area. This can be calculated at an overall health and wellbeing board level, down to a more detailed project level.

The logic here is that the more activity an organisation commissions, the more influence it has over the risks and benefits.

Once it is determined which party has influence over certain risk and benefits of the agreed arrangement (e.g. underspend or overspend of a service), it may become apparent that some risks or benefits are influenced by only one organisation. In this instance, the group should consider whether it is appropriate to share these risks/benefits or whether they should remain with the organisation with the main influence over them.

Pro rata contributions

Overspends and underspends can be allocated pro rata to commissioners on the basis of their contributions into the project. This can be in the form of one overall risk and benefits share agreement for the pooled budget, or a number of subsections within the budget for which there are different risk and benefits share agreements.

How is risk and benefits sharing initiated?

The decisions required to develop a successful risk and benefits share framework are set out as a step-by-step process below. This guide should be used in conjunction with the How to … understand and measure impact guide which provides more support regarding identifying and managing benefits measures.

The order shown is only a suggestion. Elements of the process will be iterative, and should therefore be revisited during the process if necessary. For example, estimated populations may be determined early on, but this will need to be revisited and refined to agree baseline figures.

Sharing risks and benefits of integrated care
Previous section | All sections | Next section