The final instalment in our regular briefing on new in care models and progress of the Five Year Forward View. By integration lead David Williams.

It is now the final year of the vanguard project and, thanks to a couple of significant pointers in last week’s Next Steps document, the beginning of a new phase for new care models.

This will be the last edition of this newsletter, because I’m going to lead HSJ’s coverage of the Carter efficiency agenda.

The Next Steps document makes it clear anyway that new care models should be everyone’s business, rolled out via the sustainability and transformation partnerships, rather than a discrete project. So the business of this newsletter and that of Dave West’s The Commissioner, which has illuminated the debate about STPs, will become one and the same.

Next Steps

Next Steps does three very significant things for new care models: it gives some very high level data suggesting that they might actually work; it defines success for new care models, somewhat narrowly; and it charts the path to accountable care systems – a concept this briefing highlighted a year ago.

Performance data: Two years after the vanguard programme launched, Next Steps puts in black and white the first indications that multispecialty community providers and primary and acute care systems are succeeding in containing emergency admissions growth.

There are two versions of the data – one using 2014-15 as the baseline, the other using the year to September 2015.

  England non-vanguard emergency admissions growth PACS annual emergency admissions growth MCPs annual emergency admissions growth

2016 calendar year (baseline year 2014-15)

3.3%

1.7%

2.7%

2016 calendar year (baseline year 12 months to September 2015)

3.2%

1.1%

1.9%

Both show a significantly lower level of growth when the vanguards are taken as a cohort. Some sites – Nottinghamshire, Northumberland and Morecambe Bay are named – are actually cutting the per capita rate of admissions.

Relevant context: I’ve seen unpublished NHS England data showing PACS sites had a higher than average number of GPs per 1,000 population to begin with, so might have been in an advantageous position to work on admissions avoidance from the start.

If I was feeling particularly churlish I could also point out that the PACS sites collectively had a higher baseline of emergency activity per capita than the average to begin with, so some of this might just be regression to the mean or the rest of the country catching up with them.

The document also says vanguards have seen “lower growth in… emergency inpatient bed days than the rest of England”, although it doesn’t provide data.

Here’s what we don’t yet know: are all vanguards running these models reporting comparable results, or are this apparently impressive performance being driven by a few while others lag behind? Do the PACS and MCP recipes work everywhere? Or are there other local factors at work - for example Northumbria’s consolidation of three emergency departments into a single dedicated emergency hospital – that may also explain their success?

Definition of success: Next Steps strongly indicates that success for STPs in the future will primarily be measured on those two metrics – emergency inpatient bed days and emergency admissions growth.

I reckon if I had pronounced a vanguard a failure for not showing improvement on those metrics I would have been accused of being reductive in my assessment.

Were new care models only ever supposed to be about relieving pressure on A&E?

Clearly not! According to the original 5YFV, new care models were supposed to be about setting up personalised and coordinated care – dissolving boundaries between organisations and establishing a system that was able to meet the health needs of a local population. If you ask them, most would say that is still what they are trying to do.

What does this tell us? That while the new care models project is meant to make the NHS coherent, patient-centric and focused on prevention, central leaders are under the pressure to deliver something tangible to justify past (and future?) investment from central government. And central government cares most about performance and money. NHS England has also been under pressure from other parts of the service (all those struggling on while not benefiting from vanguard money).

Enter the ACS: It now feels less necessary to invent new types of organisations and new types of contracting. After a couple of years trying to work out how to set up accountable care organisations in the NHS, it’s now clear that getting systems to work as actual systems would be enough of a prize.

Hence the emphasis in Next Steps on “accountable care systems”, and this not very encouraging passage on the ACO/full blown PACS model:

“A few areas in England are on the road to establishing an ACO, but this takes several years. The complexity of the procurement process needed, and the requirements for systematic evaluation and management of risk, means they will not be the focus of activity in most areas over the next few years.”

Translation: you probably have more important things to do.

So, farewell, then…

The original Forward View vision of PACS and MCPs, as embodied by the vanguards, is still relevant but its collision with reality has produced a more modest set of ambitions and a less all-encompassing definition of success.

In this context the announcement that national director Sam Jones is leaving next month feels timely.

For what it’s worth, her explanation of wanting to see more of her kids rings true to me.

Sam always emphasised the patient-centric benefits of new care models, and their local uniqueness, ahead of transactional processes or crude performance gains. These should be important principles as the vanguard period gives way to the era where establishing new care models becomes everyone’s job.