Rushing the development of new care models – and the collaborative relationships that drive them – is a recipe for disaster, so let’s give them the time they need, says Chris Ham
Two years on from the publication of the NHS Five Year Forward View, the new care models programme is the most tangible expression of the innovations that national leaders hope will transform the experience of patients and service users.
Both theprimary and acute care systems and the multispecialty community provider are seeking to integrate care around the needs of the populations they serve, with the most ambitious aiming to become accountable care organisations or systems. Areas as diverse as Northumbria, Salford and Birmingham are showing the way and are putting in place the governance and organisational arrangements to deliver joined up care.
Plans range from informal provider partnerships or alliances to contractual and corporate joint ventures, with in some cases the ambition of creating fully integrated organisations. Commissioners and providers have worked closely in the development of these plans but are increasingly operating at arm’s length from one another as more formal procurement processes are initiated.
Getting it right
The creation of provider partnerships of different kinds is also beginning to change the role of commissioners, with the development of longer-term outcomes-based contracts, under which accountable care organisations and systems will assume some commissioning functions and work under capitated budgets.
The spectacular failure of the UnitingCare Partnership contract in Cambridgeshire and Peterborough underlines the importance of getting the governance and organisational arrangements of new care models right. Legal advice has been sought on the options for doing so and which of these options are best suited to the specific innovations in care under development.
National bodies are also putting in place assurance frameworks to assess proposals before they proceed. As they do so, it is critically important that they focus on relationships between providers who come together to collaborate in delivering new care models and between commissioners and providers.
Our work underlines the need for an investment in organisational development to support experienced organisational leaders, clinicians and others to work together in partnerships and alliances in which they share power with others. The involvement of local authorities in some of the new care models is an asset in this regard because their leaders are usually more experienced as system leaders than their NHS counterparts.
Now more than ever, national bodies need to hold their nerve in seeing through the innovations they have helped to stimulate
Despite this, the different accountabilities and ways of working of NHS bodies and local authorities are creating challenges even where there is a commitment to joint working. The importance of “relationships, relationships, relationships” is widely recognised and needs as much attention as the technical and legal aspects of new care models.
The work put into governance, organisational arrangements, and relationship building has slowed the process of moving from plans to implementation in some areas. This has served to fuel the frustration of national leaders who, understandably, are impatient to see the results of the investment made in the new care models programme at a time when NHS performance is under intense scrutiny.
In reality, the ambitious plans under development to transform care for whole populations were always likely to take three to five years to show measurable progress. Now more than ever, national bodies need to hold their nerve in seeing through the innovations they have helped to stimulate.
Collaboration, not competition
National bodies also have a role in removing barriers to progress whether these relate to payment systems, VAT liabilities, regulation, or procurement and tendering processes. The provisions of the Health and Social Care Act 2012 continue to loom large over the NHS with the associated requirement on commissioners to act transparently and fairly in letting contracts with providers.
Going down a competitive tendering route adds time, cost and complexity to the implementation of new care models, especially where commissioners take the view that population-based integrated care can only be led by established NHS and local government providers, with the independent and third sectors playing a supporting role.
Changes to the law may be needed to ensure that commissioners are not challenged by new entrants to the market, if indeed “market” remains an accurate description of a health and social care system based increasingly on collaboration rather than competition. Similar questions are being raised in a related context about STPs which require providers and commissioners to work together to manage budgets and implement plans for the populations they serve.
New care models and STPs represent a pragmatic workaround of the central provisions of the 2012 Act, helping to avoid a further damaging top down restructuring of the NHS but are sailing close to the legislative wind in the process.
It is surely only a matter of time before Parliament will have to consider regularising these arrangements, which seem certain to become a permanent feature of the NHS landscape.
Chris Ham is chief executive of The King’s Fund. New care models: emerging innovations in governance and organisational form by Ben Collins is published today by The King’s Fund