Tracking everything that’s new in care models and progress of the Five Year Forward View. By integration reporter David Williams.

The week in new care models

  • The health and social care divide has been driving the news agenda around sustainability and transformation plans over the past week. First Birmingham published its plan, in defiance of NHS England’s communications strategy. Then the council chief executive (and local STP lead) Mark Rogers criticised health leaders for putting the NHS first rather than trying to solve the whole health and care system. Soon, other councils were joining in. There is a palpable sense of resentment at the STP process in local government: the sector feels it has been treated as the junior partner in drawing up the plans, and its approval of them is considered a formality, rather than a serious act of scrutiny.
  • NHS England chief executive Simon Stevens responded to the criticism via an exclusive interview with HSJ. Talking about whether social care should receive more funding as part of the STP process, Mr Stevens said: “Those decisions are for the people in Birmingham and Solihull to make, so I would expect they will have made those kind of judgements in the STP, which [Mr Rogers has] been good enough to produce. It would be naïve to think, and I know Mark is not naïve, that the process of bringing together partners across Birmingham and Solihull could by itself mean that the NHS was able to cover off all of the funding pressures facing Birmingham city council. That’s why they say in the STP, that Mark has chaired, that one of the things they regard as unfinished business is the national policy on social care funding. Well, the STP process was never designed to answer that particular question.” I wonder whether that tone will cool everyone down? The real problem is not so much that STPs do not solve the social care crisis, so much as the impression that they could ever do that was allowed to take root.
  • Our survey of CCG leaders, published last week, found the most widespread service change priorities are to strengthen prevention and out of hospital services, and sharing more records and data.
  • A new commissioning executive is to be formed in the Thames Valley to overcome the “significant challenge” of commissioning across an STP footprint, and will take powers from seven clinical commissioning groups.
  • Concerns have been raised over the local relationships and finances of a GP provider that has received significant backing from national health leaders. A leaked internal report for Warrington Health Plus, which stated the company’s position at 1 September, noted how its relationship with Warrington CCG had “deteriorated to the point where mutual confidence is low and new business contracts [have] become unlikely”.

Hospital chains: Can a long distance relationship work?

A few weeks ago I contributed to a joint editorial about the Five Year Forward View’s messy collision with reality.

“Soon, vanguards will start becoming contentious,” we wrote. “Hard decisions will have to be made.” Where we got it wrong was that we predicted controversy would begin erupting around primary and acute care systems and multispecialty community providers. In fact, it’s hospital chains that have caused friction in the West Midlands this week.

The plan is to set up a chain (ok, a “foundation group”) to solidify the “buddying” arrangement that has existed between South Warwickshire Foundation Trust and Wye Valley Trust while the latter has been in special measures.

Since Wye Valley is about to come out of special measures, it seems safe to assume the relationship has been productive. NHS Improvement certainly seems to harbour that belief, and is understood to have made it clear that a chain is the only option it will support.

The new chain is partly controversial because it does not have universal backing. Not everyone who might have expected to know in Wye Valley did – and it appears the WVT board has been presented with a solution and told nothing else will do. So late last week we were treated to the spectacle of the local MP Jesse Norman – a government minister – raising some pretty reasonable points about the lack of consultation, and asking sensible questions about the operating model for the chain.

This was avoidable, and note Mr Norman is not saying the arrangement is a bad idea – he’s mostly angry that he and other local players were kept in the dark.

South Warwickshire is a logical partner for Wye Valley: both are acute and community providers, based around small county towns with dispersed rural populations.

South Warwickshire is a high performing organisation – it’s one of the few trusts hitting both finance and key performance targets, and its success challenges the idea that smaller trusts can’t stand on their own. It hasn’t yet been accredited to run a chain (only four vanguard trusts have had that honour) but that will presumably be a formality if NHS Improvement wants it to happen.

Given SWFT’s reputation it was surprising the Care Quality Commission rated it as “requires improvement” in August. It is now doubly surprising that a trust that received a less than glowing CQC report a couple of months ago is now emerging as a chain leader.

But then SWFT is in the second highest “segment” in NHS Improvement’s new oversight framework – meaning it is well thought of by the sector regulator. So perhaps the CQC’s assessments and NHS Improvement’s don’t quite match up?

The big picture is that this is a trust well rated by NHSI, working increasingly closely to turn around another trust that is not well rated by the same. Via chains or otherwise, we should expect to see a lot more of this.

The case is highlighting the difference between a straightforward takeover and a chain. Normally, when a chief executive and a chair are appointed to the same positions in another trust, there’s only one direction of travel: towards a full takeover (there are examples of this in the West Midlands). It’s not clear that exactly the same will apply in this case because of the geographical distances involved: there’s an entire county between the two trusts. That probably means WVT will continue to need its own board.

This is the appointment of a “managing director” for Wye Valley is important. It gives the trust a leader whose job will be to run services in Herefordshire and will be onsite all week.

Key question: will a “managing director” be able command the confidence of the rest of the board, or will they not want to take orders from an external person they didn’t have any say in appointing and who occupies a position more junior than chief executive?

This is another reason why the chain plan is controversial. If Wye Valley has made enough progress under to exit special measures (which is expected), could the imminent departure of its current chief executive, and the appointment of a new MD who is seen as less senior, dent confidence in the organisation at precisely the point where improvements need to be bedded in?

Also, could the relative remoteness of the new chief executive and chair lead to a relaxing of managerial grip in a trust that needs to be well led?

I don’t know the answers to those questions but they are being asked locally, and the success or otherwise of this arrangement will tell us whether the chain model should be applied over wider geographies, or if it should be reserved for immediate neighbour trusts.