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

  • “Combined authorities” for health: Simon Stevens has mooted the idea of NHS commissioners and providers pooling sovereignty to put reform ahead of organisational interests. Sounds good, although the most interesting thing about the idea is not its only-in-passing resemblance to scaled-up local government, but the proposal that individual members will lose their power of veto. This might be an effective and realistic way of getting things done in many parts of the country, but it feels counter-cultural to the vanguards which if they succeed will do so generally via consensus.
  • Devo shambles on: A few weeks ago I pointed out the difficulties local authorities were having in finalising a devolution deal for Oxfordshire, because its county and district councils wouldn’t agree on who should be abolished (“not us”, said everyone). The negotiations reached a new peak of absurdity last week when, as reported by Local Government Chronicle, as the district councils’ proposal partially unravelled, and was promptly branded a “shambles” by the county.
  • Mega GP provider latest: Nottingham City; 43 practices; 312,400 population. These big new alliances are important to the business of general practice, enabling back office cost sharing, collective purchasing of locum cover, and joint bids for some large scale contracts. However, a big question remains over how many of them are mature enough as organisations to provide real leadership in their local systems. Just because setting these up is a good idea doesn’t mean that you suddenly have a load of MCPs in waiting.
  • NHS Improvement has put out a briefing note about procurement to CCGs. They don’t have to hold a competitive tender if it isn’t necessary, but they are going to have to advertise the fact they’re creating new contracts in pretty much every case. The guidance emphasises working with existing partners, and makes no mention of “most capable provider”. But, while it says there are “lots of ways” of selecting a provider without competitive tender, it doesn’t actually detail them. Expect more on this from the DH soon.
  • There will be no newsletter from me next week, because I’ll be on leave. See you again after the bank holiday.

What this year’s vanguard funding settlement means

The new care models team has announced the allocations of transformation funding for 2016-17. Here’s what it tells us:

True to their word, NHS England’s Sam Jones and Simon Stevens have prioritised funding for the areas that they have most confidence in. That applies not only to whether change is taking root, but also whether national leaders believe that the money they put in will generate a financial return. New care models are supposed to be better value, and have written business cases to demonstrate this. The funding shows you which of these cases the national leaders found convincing.

But, it doesn’t necessarily follow that the strongest vanguards are getting more, at the expense of the weak ones.

For instance: Although Wirral Partners PACS is receiving next to nothing next year, its share of transformation funding isn’t being redistributed among the more favoured PACS.

In fact, Northumbria, one of the best regarded PACS vanguards, is also getting less money in 2016-17 than it did last year: its allocation is dropping from £8.3m to £4.3m.

It’s the same in other parts of the vanguard: funding is being removed from West Cheshire and Calderdale MCPs this year. But Sunderland, one of the most widely tipped MCPs, is still only getting £4.8m this year. Although that makes it the best funded MCP, it’s still a significant cut from the £6.5m it received last year.

The reason for this is there has been a redistribution of funding between the five types of the vanguard.

Overall, PACS and MCPs are losing out considerably. The care homes vanguards, which are known to have particularly impressed Sam Jones because of their collaborative approach and some encouraging early results, are also getting less money: £5m between them, compared with £6.6m last year.

The beneficiaries are the acute care collaborations – the hospital chain vanguards. Funding for this cohort has nearly doubled, to £26.4m.

Why?

There are three main reasons.

The first is that the allocation for chains in 2015-16 was not a full year of funding: while MCPs, PACS and care homes vanguards were identified before the beginning of that year, the chains were only named in September. So 2016-17’s allocation better reflects the cost of a year’s worth of work.

The second is that the chains have the confidence and enthusiasm of the national leaders, and have been judged to be worth investing in.

The third is that the chains are seen as having a good chance of contributing to the two big strategic challenges which the Five Year Forward View aims to solve: turning the NHS into a population health management system, and becoming more efficient.

This is particularly true for chains that apply to the whole acute system – such as the handsomely invested-in Royal Free, or Salford. And, while PACS and MCPs aim to reinvent primary care, chains seek to affect similarly radical change on the acute side.

Care homes vanguards, while impressive, are seen as being more “niche”, in that they aim to improve care for a sub-set of the population, rather than dealing with the whole system or a big swathe of the provider sector.

In contrast, giving hospital chains £26m places them on a more equal footing to the PACS (£31m) and MCPs (£37m). From now on, think of PACS, chains and MCPs as the core three types of vanguard.

Given that there was about £300m of transformation funding to spend this year, compared to £200m last year, it is surprising that the amount for vanguards has shrunk slightly. What will the rest go on?

We don’t know details, but as last year, the national new care models team is funded out of this pot, as are a number of other national schemes such as the success regime and diabetes prevention.

NHS England also has a new load of workstreams to implement that it didn’t last year: a mental health one led by Claire Murdoch, a maternity one led by Sarah-Jane Marsh, an emergency one led by Pauline Philip, and a cancer one led by Cally Palmer. We don’t know how much those schemes will cost: don’t assume £100m just yet.

This year’s vanguard funding begins to tie the programme into the sustainability and transformation planning process: the cash is a slice of a slice of the national “sustainability and transformation fund”.

Therefore, it is governed by the same rules as the rest of the £2.1bn fund – you only get the cash if vanguard members agree to their control totals and deliver on them. In future, the link will be strengthened: decisions on whether to invest in vanguards are likely to be influenced by how good the local STP is, and how aligned the two programmes are.

Investment in vanguards is likely to become more conditional in another way, too. Vanguards have been co-designing the details of MCP and PACS models, and the results of this work will begin to circulate this summer. It will begin to define what MCPs and PACSs are and are not and vanguards, if they are to continue to be supported, will be expected to conform to the model – and to do it all.

This will likely cause vanguards to compromise on how they constitute themselves, or what they do, but the gain will be a model that can be applied anywhere – by any STP. It is another example of how 2016-17 is intended to be the year the Forward View shifts from theory to implementation.