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

  • Although this year’s NHS Confederation conference didn’t yield any big new announcements or revelations on new care models (perhaps I was in the wrong breakout sessions, or the wrong bars), there were a few significant indications of how the programme is developing.
  • My favourite was Lord Prior’s attempt to manage expectations about how quickly new care models could be rolled out. Musing on the time taken to establish accountable care organisations in the US, Lord Prior said that if we had 20-25 per cent of the population of England covered by a PACS or MCP by 2020, we’d be progressing pretty quickly. Thing is, the new care models team wants PACS and MCPs to cover 50 per cent of the GP listed population by then.
  • In a throwaway line during a question and answer session after his well received speech, Jim Mackey suggested that the future might not involve nominating your local provider and shovelling the local budget at them and calling it a “capitated budget”. Just as “payment by results” incentivised access to elective care, could there be a way of incentivising discharge from hospital to community or social care services, he mused.
  • Sam Jones said that vanguards were achieving a 20 per cent reduction in accident and emergency admissions, up and down the country. We need to see the data that backs this up. My expectation is that it is likely to apply to cohorts of people for whom the model has changed under the vanguard, for instance those in care homes, rather than an entire population, although that is not to diminish the significance of such a rapid improvement in performance.
  • There were also a couple of interesting lines about sustainability and transformation plans. Amanda Doyle compared being in charge of one to being a parent of small children, in that no one pays any attention to anything you say, and you do it because you care, not because anyone ever says thank you.
  • Meanwhile Jeremy Hunt said that STPs were about reducing the rate of bed days and A&E admissions per 1,000 population. They’re about a good deal more than that, but the choice of indicators is telling: those are two of the main metrics vanguards are being measured against, and STPs are the replication and implementation mechanism for new care models. 
  • Mr Hunt had precisely nothing to say about social care, which remains a policy-free zone. That omission contrasted significantly with Simon Stevens’ acknowledgement that social care funding was unfinished business, as he revealed he is pushing publicly and behind the scenes for a resolution.

Sir David Dalton on hospital chains

Last week I wrote at length about hospital chains and some of the policy holes that need filling this year.

Sir David Dalton, chief executive of Salford Royal, who basically invented hospital chains in the context of NHS providers and is setting one up himself, has replied to each of the eight questions I raised about chains.

Since starting this briefing newsletter I’ve encouraged readers to respond and contribute, so I’m going to give this edition over to Sir David’s thoughts on the issues I raised, one at a time:

WNiCM asked: How big should a chain be?

Sir David Dalton said: “The ‘sweet spot’ for a ‘group’ of healthcare organisations would be coverage of 1-2 million population. This would suggest a ‘group’ might consist of between four and eight locality organisations. Below 1 million, scale benefits are not maximised, over 2 million there would be diseconomies of scale due to high complexity of organisational arrangements. Organisations within the group must have geographic proximity (at least initially) to create strategic service change opportunities.

“For me, a ‘chain’ is created when two or more ’groups’ of geographically associated organisations are incorporated under common governance arrangements.”

As long as we don’t get too precious about terminology, that fits well enough with the Royal Free’s business plan of linking 10-15 trusts.

WNiCM asked: How can hospital chains be established quickly?

Sir David said: “The group differs from a merger in that it seeks to avoid the distraction and time of a substantial merger transaction, whilst delivering much of the benefits. It also allows a higher degree of operational autonomy for members and retained locality relationships. The startup of a new form of governance needs careful consideration and will take time. Once systems are established, access into the group will be speedier than a merger and acquisition transaction.”

So growth might speed up once new forms of governance are established. Such as…

WNiCM asked: What will the accreditation process do?

Sir David said: “The NHS should receive adequate assurance that a group’s leadership and governance arrangements are most likely to achieve stated objectives of patient benefits.

“I would expect a short assessment to be necessary which can draw from existing data sources. The purpose of the change is emphatically not to increase scale and control for the pleasure of leaders! [Presumably national leaders?]

“It seems right to me that those organisations who are judged to be comparatively successful are encouraged to support those who are not – and those who have continued to struggle with services which show little evidence of improvement to be compelled to cede their sovereignty. What is important here is that the interest of the population is put ahead of the self interest and preservation of organisations.”

That last point on self-interest could cut both ways, of course: organisations that can’t improve will cede sovereignty, but sometimes a successful organisation will have to support a struggling neighbour even if it is not in its immediate interests to do so.

WNiCM asked: Is competition and choice a worry?

Sir David said: “Most often patients have or exercise little choice, other than to receive care from a local provider regardless of the quality of services offered… In short, though, the interest of patients should always trump the interests of competition policy and the interests of organisations.”

WNiCM asked: How will the impact of chains be measured?

Sir David said: “I believe this to be relatively simple. Each group will be required to state what their ‘value proposition’ is and this will be capable of assessment. In addition, there will be the usual array of performance indicators.”

The outstanding question, then, is whether there is a bespoke assessment regime for each group/chain, or whether there’s a common one. Given groups will probably emerge gradually, one standardised service line at a time, rather than in a big bang moment, the former seems more sensible.

WNiCM asked: What about far-flung trusts? [ie: should chains accommodate organisations from the other side of the country]

Sir David said: “I do not see this being a reasonable proposition in the near term. The benefits of grouping by geography is the best way of getting to the value quickly. That is not to say that some trusts could not be ‘associated’ members and subscribe to the group in order to get access to benefits. But participating in common governance, where accountability and decision making is clear, provides the best means of taking decisions quickly (limiting negotiations between trusts on strategic change options). The ‘pace to value’ equation is at the heart of successful groups/chains.”

Note the emphasis on “getting to the value quickly”. This is what gives this policy agenda its energy.

WNiCM asked: What is the right leadership and governance structure for a chain?

Sir David said: “This topic generates heat and there are a variety of views, each valid, but it depends on what you wish to give importance to.

“In my view, to deliver benefits quickly, a group should comprise a ‘group HQ’ with responsibilities for strategy development, service change, development and implementation of standardised operating polices; capital planning and asset renewal.

“The local organisation, as a member of the group, through a ‘scheme of delegation’, enables the group HQ to undertake the above activities on their behalf whilst retaining responsibility for operational excellence, delivering the group’s agreed plan and local stakeholder relationship development.

“There will probably be different categories of membership ranging from full/integrated, associate/federated to affiliated/subscribing. There will be more work to do here in the early stages of establishment.”

This sounds pretty similar to what the Royal Free is proposing. The “heat” referred to above may well relate to the terms under which new members might be persuaded to join a group/chain.

WNiCM asked: How will chain-leading FTs be inspected and rated?

Sir David said: “The group must be capable of functioning when one or more local organisations has a poor rating or experiences poor performance. Otherwise there is no incentive for groups to support troubled organisations. I would expect similar CQC inspection arrangements to those currently in place in non-NHS groups/chains.”

So that’s a pretty clear call for his chain or those like it to be regulated on a site by site basis, like private providers are, rather than given an overall organisational rating.

Your move, CQC.

Dalton: Change to private sector style inspections for chains