Dorset’s journey to becoming an accountable care system

Dorset’s journey to become an accountable care system (ACS) involved a three-year programme of work. This included a new focus on co-design, open and honest dialogue, some difficult conversations and the cultivation of strong relationships between partners old and new.

This cannot be done quickly and there are no short cuts – especially where clinicians who care deeply about creating the best outcomes for patients are concerned. Combine this with navigating the complex assurance process needed for success and it can be a long process.

In the first few months after Dorset Clinical Commissioning Group’s establishment, we realised that there was an impending and urgent need to review clinical services within the county. In common with much of the rest of the country we faced huge pressures, so we began to define the case for change.

This centred on an ageing population, rising numbers of people with long-term conditions, escalating workforce pressures across primary and secondary care, a variation in quality of care and outcomes for people, and the impending and growing financial crisis. These were the compelling drivers for change.

Our Clinical Services Review was launched in October 2014. Initially focussing on acute reconfiguration, the CCG led a series of clinical working groups initially monthly over a period of six months, and later extending to 13 in total as we encompassed community care.

More than 600 primary, secondary and community care clinicians came together and after each group there was a period of reflection, review and opportunity for further input to the discussions before moving to the next meeting.

We discussed our aspirations for a better health care and system, bringing forward national and international examples of good practice, and together we created a vision of ‘what good looks like’.

This was a fast paced piece of work. The work streams were divided broadly into clinical areas and through the months we worked together to paint a picture of the model of care for Dorset.

Essentially, this way of working provided the right forum for discussion, debate – sometimes disagreement – but importantly relationship – building across the system.

A consensus formed for a model of acute care with one major emergency hospital focusing on 24-hour consultant delivered care in line with the Keogh Review principles, and one major planned care hospital sitting in the east of the county. Alongside these, a hybrid major and planned hospital would sit in the west of the county, taking account of its distinctive  rurality.

Considering a long list of site-specific options and reducing them to a short list gave us options to further evaluate based on a series of criteria that had been established in advance.

Reference groups were established – clinical, finance, estates, patient, workforce – to work through the implications of the changes planned.

Recognising that the focus could not solely be on acute hospitals and that the out of hospital model of care was critical to the success of the system meant that very quickly we moved to a review of community services. This included the model for integrated community care and options to redesign services in each of our 13 community hospitals.

There was an increasing focus on sustainability and transformation of primary care as the bed-rock of community care. Acute mental health pathway redesign ran in parallel.

Working alongside local authority partners more closely for the first time brought a whole new set of relationships and a focus on whole system solutions including prevention.

There were many challenges around organisational alliances and resistance to change. The sheer scale and complexity of this cannot be underestimated and consistent leadership behaviours need to be maintained always.

What started as a piece of work around the acute sector rapidly and rightly became a whole system review, and consultation on the potential shape of the Dorset healthcare system has now been completed.

The NHS has historically evolved little by little, with services growing piecemeal without thought to the wider system.

While seemingly obvious, review at this scale rarely happens. Strategically it is absolutely the right thing to do but cannot happen without honest engagement of clinicians, patients and managers who have come together to share a common vision based on a strong case for change.

The need for excellent, even relentless, communication and engagement is paramount and cannot be underestimated.

Building trust between new partners, identifying key stakeholders to act as agents for change within their organisations and supporting these new leaders is critical for success on this difficult but worthwhile journey.

Karen Kirkham

Karen Kirkham has been a GP for over 25 years and is now senior partner in a large practice, combining this with a senior leadership role in Dorset.

She also has a national role as Senior Medical Advisor to the Primary Care Provider Transformation team.

Karen is currently focusing on the redesign, transformation and delivery of the integrated community services and primary care component of Dorset’s STP.

During 2018/19 she was a national clinical advisor for primary care with the NHSE System Transformation team.

Leave a Reply

Your email address will not be published. Required fields are marked *


  1. Steve Trevethan says:

    You refer to the need for excellent, even relentless communication.
    Do you have a policy on your responses to e-mails?
    I have yet to receive answers to relevant questions, the first of which was sent in January 2017.
    On the occasions that I do receive a reply it is typically in a form which is inappropriate for the modal citizen.
    My last request for information on ACSs covered 87 sides of A4 paper.

    • NHS England says:

      Dear Steve,

      Thank you for contacting NHS England.

      Please do contact the NHS England Customer Contact Centre again. If you still do not get a response or not happy with the way your correspondence has been dealt with and would like to take the matter further, you can contact the Parliamentary and Health Service Ombudsman (PHSO) which makes final decisions on unresolved complaints about the NHS in England. It is an independent service which is free for everyone to use.

      To take your complaint to the Ombudsman, visit the Parliamentary and Health Service Ombudsman website or call 0345 015 4033.

      Kind regards,

      NHS England.

  2. Tim Deegan says:

    Dear Dr Kirkham

    Our very rural locality in south Somerset based around 3 small market towns and covers approximately 45,000 patients. We have recently heard from our CCGs new chief officer that Primary Care at Scale is going to be driven forward in Somerset over the next two to three years. I attended the Best Practice conference in Birmingham last week where you spoke about the Dorset experience of working together. I am keen to find out more about how you did this in particular what first steps practices took to start working together more meaningfully. Would it be possible to discuss this briefly via email?

    Many thanks for your time

    Dr Tim Deegan
    Summervale Surgery, Ilminster

  3. Jon Orrell says:

    Clinical services review can also be interpreted as making deep cuts in NHS provision. An ideological and political process driven by a Conservative government that does not fundamentally agree with publicly provided healthcare. For our locality it means the loss of two community hospitals and a mental health unit together with downgrading two of the three Dorset main hospitals. The Kings fund points out we already have too few beds , too few nurses and too few doctors. This CSR process makes matters worse. It will also lead to more charging of patients for care as home based therapies will become chargeable for the social care element that would have been free in an NHS bed. The carrot held out to pliant doctors is of local control. The reality of accountable care organisations risks being a simple stepping stone to franchising NHS provision as part of a post Brexit deal with the USA. Simon Stevens came to run the NHS from an American Corporation. Hunt backs privatisation.