The week in new care models

It has been a huge week in new care models and health policy generally. There are at least three things I could have written about at length this week.

  • Dudley! I gave a talk at the recent NHS Providers conference about great communications catastrophes caused by a lack of openness and transparency. Being secretive, and creating an information vacuum, is a dangerous game in the NHS – and one Dudley Clinical Commissioning Group is gratifyingly reluctant to play. This week HSJ revealed the CCG has become the first place to begin procuring a multispecialty community provider. The CCG has put lots of information out about its development of an MCP, and in doing so has helped demystify the whole process.
  • Here’s what we don’t yet know about Dudley: are GPs actually onside, or is there the normal distribution of enthusiasts, slower adopters and refuseniks? What do you do about the latter? Who is going to bid? Will any private firms get involved? Will the acute trust, The Dudley Group, bid? The latter is pertinent because it’s the only foundation trust on the patch, meaning it’s the only NHS organisation that can set up a subsidiary company which could potentially form a joint venture with other parties.
  • Yeovil! It looks like this primary and acute system vanguard could take over another seven GP practices, putting it in direct control (via its subsidiary company) of the majority of local practices. This is a major step forward for the area, and for the PACS model. Although other PACS are likely to go live on a new contract sooner than Yeovil (such as Northumbria), Yeovil has made by far the most progress in formally bringing GPs into their business. I’ve written a lot this year about the delicate work of persuading GPs to give their businesses to the new model of care – if Yeovil bring in 10 practices in a year, this really is impressive. There is some sensitivity about the terminology here: is it a takeover, is it “integration” or is it a partnership? Generally people involved in this sensitive work prefer softer language, but in terms of the transfer of people and potentially assets, it’s a takeover.
  • Here’s what we don’t yet know about Yeovil: are Yeovil District Hospital Foundation Trust’s financial problems severe enough to slow its progress through the assurance process all PACS will have to go through before they can take on a new contract?
  • Stockport! The MCP vanguard is planning to revive the “care trust” model, which brings together GPs, social care, and community provision. There’s no reason why this couldn’t be adopted across the Greater Manchester devo area, if there’s the will.

Staffordshire’s mega-contracts are a relic of the pre-forward view era

I was surprised to see that Staffordshire’s huge cancer and end of life contracts have been given the go ahead.

Recap: these two giant outcomes based contracts were first mooted in 2013, and were quickly awarded integration pioneer status by then care minister Norman Lamb. The idea was to appoint a prime provider for each contract to integrate previously fragmented services. Progress was gradually made towards awarding the contracts until early 2016, when the procurements were paused following the UnitingCare Partnership contract collapse. The Staffordshire contracts were huge and novel, and therefore intrinsically risky. Plus the now defunt Strategic Projects Team, which advised on UnitingCare, was also involved in Staffordshire.

NHS England reviewed the contracts and now they have been un-paused. The cancer contract could be awarded within the next two months, with end of life care following next autumn.

The Staffordshire project predates Simon Stevens’ tenure as NHS England chief executive, and quite a lot has changed since it was launched. “Integration” doesn’t mean quite the same thing in 2016 as it did in 2013. In the past three years we’ve had the Five Year Forward View, new models of care and the vanguards, which all overwhelmingly focus on “population health” rather than single pathway integration.

The Stevens-led NHS does seek to integrate and improve single service pathways too – see the acute care collaboration on orthopaedics, or the cancer taskforce – but does the Staffordshire cancer pathway fit with the work now being done nationally by Cally Palmer? Hopefully someone has checked.

Although national leaders aren’t completely averse to single specialism outcomes based contracts, they are clear that you can’t build a population budget out of a mosaic of single service contracts. They want to avoid a scenario where it becomes impossible to set up a PACS on a capitated budget because there are already lots of individual long term contracts for single pathways. The two Staffordshire contracts would certainly punch two big holes in any future MCP or PACS.

The method being used in Staffordshire feels at odds with the new care models approach. No one involved in the vanguards seriously thinks you can award a massive contract to a new provider and expect services to integrate automatically. Part of the reason new care models are taking so long to be formally established is that people are (sensibly) focusing on the relationships and working practices first, and leaving the contracting until much later in the process.

Another complicating factor: the Staffordshire STP covers six CCGs, but only four are involved in this contracting exercise. Assuming this notoriously fractious patch does come up with a viable sustainability and transformation plan (nothing has been published yet), these contracts may make it harder to begin whole system working.

Lots of work has been done in parts of Staffordshire on the cancer and end of life care pathways. National leaders have decided it is better to go ahead than to abandon the tender. Presumably the work done so far is of good quality.

Let’s hope so, because, on the face of it, this exercise is a relic of the pre-forward view era and cuts across the generally sensible approach to new models of care being taken elsewhere.