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

  • I’m writing this week from the first day of Conservative Party conference in Birmingham. Little formal health policy action so far – maybe I’ll have more to share this time next week. However, one point from a fringe session on primary care and technology: Jeremy Hunt is, as he has been for the past four years, evangelical about the transformative potential of technology for healthcare. He’s particularly enthusiastic about apps to help people manage their own conditions and an online 111 service, either of which could be linked to a person’s electronic patient record. That’s fine – and, even better, it doesn’t contradict what the Five Year Forward View is trying to achieve with new care models. But I’m not sure what the Department of Health’s delivery mechanism is for it. The mechanism the NHS does have is the new care models programme and sustainability and transformation plans. While many vanguards are working on improving their digital offer, Mr Hunt’s themes feel like a parallel policy to new models of care, rather than an integral part of them. I suppose that’s just what happens when, in the DH and NHS England, you have two policy units instead of one.
  • Did I mention how much I love Dudley? This pretty advanced multispecialty community provider vanguard continues to delight with its openness – now it has published more details relating to its upcoming procurement. We now know the MCP will be prevented from making “excessive” profits. Is this a national policy, or a reflection of local tastes? We don’t know yet. What’s “excessive”? We don’t know that either – it probably depends on who bids – but this is potentially a boost for an NHS trust or social enterprise bidder. The key question now: will there be enough margin for it to be worth a private firm bothering to invest? Given the whole NHS is bust anyway, this is possibly a moot point for the time being.
  • Geraint Lewis, NHS England’s chief data officer, has written about the importance of data analytics for new care models. Mr Lewis has previously worked in the US establishing accountable care organisations, and says they had to grapple with many of the same issues as the NHS. Interestingly, in his blog he also mentions that he is leading the “care model design” workstream for new care models. That sounds like an important (or even all encompassing) one – and perhaps it is an important statement of intent that it is being led by a data specialist with a background in public health.

Is Northumberland about to establish the NHS’s first ACO?

Last week NHS England published the much anticipated (by me at least) policy framework document for primary and acute care systems.

It reveals, as we expected, that a couple of PACS sites – Northumberland and South Somerset – are planning to go for “partial integration” next year, but nowhere is going to go for full integration until 2018 at the earliest. We’ve got a detailed story on Northumberland on hsj.co.uk.

The national new care models team’s template PACS contract is not currently expected to be published until summer 2017.

But even that might be faster than any vanguards can realistically progress: Northumberland doesn’t seem to be in a hurry to leap from partial to full integration, and it may be just as likely to stick with its new arrangements for a few years.

HSJ has already made the point that this means the first fully fledged vertically integrated ACO is still a couple of years away, so I won’t labour it here. Regular readers will have heard me say before that the hardest thing about setting up these new models of care is involving the GPs – encouraging them to commit to forming a new organisation, all together at once, despite different practices being in different states of readiness and enthusiasm.

Coaxing the GPs in to work with a PACS is particularly challenging because that model is seen by some as a takeover by a foundation trust. That interpretation misreads the model – a successful PACS is much more likely to be a partnership between acute provider and primary care than one gobbling up the other – but in many places the GPs don’t have a huge amount of trust in either the local acute provider or the national leaders who came up with the idea.

In the case of Northumberland, GP involvement remains a work in progress. The final PACS organisational form has not been announced and GPs are still considering the vehicle they will use to speak with a collective voice at the ACO table – a federation, joint venture, alliance or something else. The hard work of then agreeing what the ACO should actually be in its final form, and then setting it up, is another matter again. GPs are represented on the Northumberland ACO board, but until their services are included in the whole population budget, talk of the NHS’s first ACO is a bit overblown.

Let’s not be overly negative though. It is a big step for a single trust to be awarded a single contract for acute, community and mental health services, freeing everyone from the perverse incentives of payment by activity.

Better still, the procurement aspect appears to be progressing relatively painlessly: the prior information notice to alert the market of the new contract was published, and Northumbria Healthcare FT was not challenged. The NHS can still find plenty of other ways to screw up on procurement, but at least in this case it hasn’t wasted too much time and effort on the process.

Another note of positivity: ACO or not, fully integrated or otherwise, Northumberland does have an impressive story to tell on at least one key metric. The rate of emergency admissions per 1,000 population steadily fell in 2015-16 after it started working on the PACS model, against the national trend, and despite the increase that national analysis suggests would have happened if they had not done anything at all.

That’s encouraging, but only for Northumberland – not for all PACS sites. Why? Because the big thing that has changed there in the last couple of years is the opening of its new specialist emergency care hospital in Cramlington. This is a key part of Northumberland’s PACS offer, but would have happened with or without the new care models programme and the option will not be available to all PACS sites in a hurry.

We should be encouraged that the Northumberland partners are showing the goodwill to get as far as they’ve got.

But due process is as important as goodwill. We’ll know ACOs are real when we know how the accountability around them works. So, soon we will need to know:

  • If Northumberland goes wrong in quality, performance, safety or finance, will it be allowed to fail? Or is it too important for that? And if so, how should keeping it afloat be managed?
  • And, in the event of anything going wrong, who is the “ACO board”, which represents all the key players, accountable to?

Contract to be let for pioneering 'ACO'