Tracking everything that’s new in care models and progress of the Five Year Forward View. By integration reporter David Williams.
When is a vanguard not a vanguard?
At the outset of the vanguard programme, new care models director Sam Jones said that some sites may well be de-vanguarded (not her phrase) if they weren’t able to deliver new care models. And she added, that will be OK because this is new stuff, for some places it won’t be the right time and for others they might end up delivering something different from what was intended.
It was refreshingly honest at the time, and remains absolutely the right position to take: NHS England should not invest in sites that do not command its confidence, and vanguards should be challenged to demonstrate that investment in them will be money well spent.
It looks as though for some sites that challenge has been tough enough to put them off applying for any more financial support for 2017-18 – the final “vanguard” year.
Transformation funding was always one of the main reasons to be on the programme, but three vanguards will be penniless from April: Wirral PACS, Calderdale MCP and Lakeside MCP.
When NHS England revealed just before Christmas how much money everyone was getting, three places had “n/a” where everyone else had a number in “£m”.
Why would they not bother applying? Vanguards do complain about the onerous process of producing a detailed “value proposition” every year, but they generally think it is worth the bother because it offers the prospect of getting a few extra million quid to spend developing their model.
True, the unfunded three didn’t get very much cash last year – £75,000 against an average of £2.6m – which amounted to a pretty clear no confidence vote from central budget holders.
However, the West Cheshire MCP didn’t get very much for 2016-17 either, and their allocation has gone up for 2017-18.
So are the unfunded three still in the vanguard? The new care models team say yes – all 50 projects are still on board.
It’s fair to say that they might be in the club but are clearly no longer enjoying the full benefits of membership.
Or, as Julian Patterson alluded to on Twitter, there is a fine and not altogether meaningful distinction to be drawn between a dead parrot and one that is merely resting.
- While we’re on the subject of who gets what money next year, regular readers may have noticed it’s gone a bit quiet on the national rollout of primary care home and enhanced health in care homes. It’s still happening, I understand, but has got a bit held up as it is closely related to other important pieces of work this winter/spring.
Northumbria ACO hits a snag
Speaking of things not happening as rapidly as expected, the Northumbria accountable care organisation’s wildly ambitious timetable has become a bit less wild.
How much less, we don’t know: they were aiming to become a partially integrated PACS from April, and they haven’t said what the new go live date will be.
Details dribbled out via CCG minutes of a joint committee meeting.
Why the delay? Well, some of this is just going to be “regression to the mean” – a very ambitious area anxious to move very fast discovering that actually it can’t go much faster than everyone else after all.
The immediate reason why Northumberland can’t get going as quickly as it would have liked is “milestones” – or the number of them that have to be passed before the new contract can go live.
This relates to the “integrated support and assurance process” launched last year in an attempt to make novel contracting a bit less likely to lead to provider failure.
After the UnitingCare Partnership embarrassment, who could disagree that more and better oversight is needed?
Well, there is a riposte from Ben Collins of the King’s Fund from December. Read the whole thing, but to summarise: he argues that the ISAP regime requires too many submissions; it will inflate transaction costs; and no commissioner will ever be able to design a risk free 10-15 year contract, no matter how much due diligence they do. There is a case, he says, to “clarify uncertainty upfront”, and then focus instead on a procurement process and payment mechanism that copes better with that uncertainty.
The CCG has also revealed that Northumberland GPs have decided how local practices would be represented within an ACO, with a federation approach being the preferred option. “Ultimately this could then progress to a form of joint venture,” the papers said. So that sounds like Northumberland GPs are leaning towards the Yeovil model, keeping their independence and then achieving a fully integrated PACS by setting up a new company jointly owned by GPs and the trust.
There is a more serious issue facing this PACS than its governance structure or all the hoops it has to jump through: the money.
Both Northumberland and North Tyneside CCGs have been rated inadequate, largely due to their finances. Northumbria Healthcare FT is likely to post a £30m surplus this year, but it’s not clear that, beyond April, its solvency will be enough to cover the commissioner-side deficits (that’s putting it politely).
So while the ACO approach represents a sensible stripping away of continuous transactional niggling in favour of spending the money available for care on care, if there isn’t enough money in the system to cover population need you might just end up setting up organisations for failure.
Which, of course, was the main lesson from UnitingCare: the cleverest provider model in the world will still fall over if you don’t fund it properly.