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

  • A few weeks ago I raised the issue of governance, and how new care models really needed robust systems of accountability to ensure safety and effective leadership. More on this from Kieran Walshe of the Manchester Business School: the NHS ignores the law at its peril, he argues. Many reforms, such as devolution, “make a nonsense of the Health and Social Care Act 2012.” But there are downsides too. “Public consultations, board meetings and formal, open ways to make decisions and to challenge them are likely to be replaced or subverted by backroom deals and horse-trading… Imagine how a future public inquiry into a major failure in care like Mid-Staffordshire might deal forensically with the muddled accountability and administrative complexity of the NHS today.”
  • A good blog from Ben Gowland of Ockham Healthcare, rounding up the recent developments in primary care. Will GPs sign up to the MCP contract? Mr Gowland writes: “I spoke to Tracey Vell, the local medical committee GP lead for the implementation of the new contract in Manchester, and she told me practices are falling over themselves to join for three main reasons: a way out of the current pressures; because they will be bought out of their building; and because the new organisation will pick up indemnity.”
  • Devolution is off in the north east, my colleagues at the Local Government Chronicle report. Seven local authorities have refused the government’s offer for devolved powers. Is Theresa May keen to continue to try to make these arrangements work, or will we now start to see this policy retreat in all but the most advanced areas?
  • A quick apology: I got a number wrong in my last newsletter. I said the North East Hampshire and Farnham vanguard had asked for £7.9m of transformation funding – it was actually £5.8m. Sorry for the mistake.

What counts as a PACS?

At the end of this month we are expecting an important publication from NHS England about primary and acute care systems – the ambitious vertically integrated providers being trialled in nine sites around the country.

It will follow July’s publication of a similar framework document setting out what an MCP is, and isn’t, and how it will be established.

The PACS document is likely to take a similarly pragmatic approach to the MCP one, offering local systems a set of options for how they formally adopt the new model of care, from “virtual”, meaning acting like a new care model while retaining the old structures, to “full integration”.

With all that in mind I’ve been looking through Salford’s vanguard plan, and have been struck by three important differences between it and the definition of a PACS I originally had in my head.

The first is a welcome addition: the Salford model has social care its core. When the Five Year Forward View came out, social care was not listed as a feature of the PACS or MCP models, even though everyone knew a shift to a preventative model of care would necessarily involve council commissioned services, or it wouldn’t work at all.

Salford Royal Foundation Trust is one of a number of NHS providers which have taken firm steps towards formally integrating health and social care provision this year (see also South Warwickshire, Oxfordshire, Wirral).

Salford says it is establishing an “integrated care organisation” (ICO) to provide both health and social care, and sub-contract mental health services. 

What the ICO isn’t is an ACO (accountable care organisation). Although an Americanism with no clear definition in the UK, an ACO is generally agreed to mean a single provider – or network of providers - responsible for the health of an entire defined population.

And this brings me on to the second difference between what Salford are planning and what I thought a PACS was supposed to be: the GPs aren’t in it. The clue, after all, should be in the name: PACS begins with primary care. But not in Salford.

This is odd, given the lengths other PACS are going to, to coax GPs in. A few months ago I detailed the latticework of linked providers, corporate vehicles and funding flows being constructed in south Somerset to enable a single organisation to take responsibility for acute and primary care without annoying all the GPs. Northumbria, too, have gone public with their plan to establish a single provider of primary and acute care, and while Morecambe Bay prefer to talk about “systems” rather than organisations, the aim is the same.

In Salford there are efforts to bring GPs into the integrated structure, but they are not yet part of the PACS and full integration isn’t likely any time soon.

Finally, on population health, I had always thought PACSs would be accountable for the combined lists of all the GP practices that were on board (admittedly a moot point in Salford’s case, as there are none). But Salford has further limited the scope to adults only, rather than the total population of Salford CCG or Salford council, for example.

This is curious because in Salford, as part of the Greater Manchester devolution project, council and NHS services will be more closely aligned than in many other parts of the country. Councils commission a range of children’s services that are very important to population health – particularly as it relates to early intervention and prevention – such as health visiting and school nurses.

My understanding is that the Salford system is pretty well aligned, no matter who is providing and commissioning. Still, there is always an argument for tying everything into a single contract for the sake of what might happen if the goodwill between the various players were to break down or if key individuals left.

Salford hasn’t been thrown out of the vanguard for heresy, so obviously the definition of a PACS is a bit less strict than I thought. Perhaps for them the calculation has been to move fastest where there is most potential to advance – health and social care integration began on that patch years ago, and maybe more work still needs to be done to build trust with GPs and convince them to scale up.

So maybe the Salford PACS will grow into children’s services and GP services over time. For now, it makes sense to understand it less as a “theory of everything” for the local population, and more like a component of a bigger integrated system incorporating the Royal’s specialised services, hospital chain ventures and the wider public service fusion offered by devolution.

“Horses for courses”, as ever, is the new care models motto.