The NHS is being told to overhaul services according to a set of six “models of care” in order to create a “sustainable health and care system”.

Landmark guidance published by NHS England today sets out how services should develop over the next five years.

It also confirms finance rules and expectations, including asserting that “hospital emergency activity will have to reduce by around 15 per cent” by 2015-16 in order to fund the government’s mandated pooled budget with councils.

The planning guidance signals a shift to separating commissioning and provision of services based on different populations’ needs, and different pathways.

It says: “We know that different, identifiable groups within our population have different needs… NHS England believes it is now time to… propose a direction of service development, based on meeting the needs of whole populations, to be applied consistently across the country.”

The models include:

  • A “modern model of integrated care… for the 5 per cent of patients with multiple, often complex, mental or physical long-term conditions”, including the elderly and frail. This could be “developed out of existing NHS trusts or foundation trusts, out of extended primary care built on general practice, or through new offers”, NHS England says. To support this, CCGs must spend around £250m nationally for services – likely to be from GP practices – to help GPs in “improving quality of care for older people”.
  • For the fifth of the population with a moderate long-term condition, commissioners should create primary care “provided at scale”, with “a broader range of services… centred on a much more pivotal and expanded role for general practice”.
  • For urgent and emergency care there should be a move to a model where “as many patients [are] treated as close to home” and “networks… with major specialised services offered in between 40 and 70 major emergency centres, supported by emergency centres and urgent care facilities”.
  • Concentration of most other specialised services “in some 15 to 30 centres”.
  • Better use of technology and public empowerment to reform services.
  • Plans to provide “a step-change in the productivity of elective care”.

The guidance claims that to support these models: “Commissioners will be equipped with the tools to enable longer-term, transformational, outcomes-based commissioning approaches.”

It acknowledges there are problems “we need to resolve nationally” to allow localities to make these changes, related to finance, regulation, leadership and workforce. NHS England will attempt to address these in the spring and summer, it says.

CCGs have to submit operational plans covering two years and strategic plans for five years in April and June respectively, showing how they will move to the service models. CCGs will lead the work for their area. However, for the five year plans, they are encouraged to work across larger “units” than their own patch, and with providers, health and wellbeing boards and others.

NHS England local area teams must work with CCGs to create an “integrated strategy for out-of-hospital care” for each area, including primary care and “wider community services”.

The planning guidance was due to be put before NHS England’s board in draft today and is expected to be sent to NHS organisations later this week, along with funding allocations for 2014-16, which are also being debated at the meeting.

Finance rules and expectations

The draft guidance sets out overhauled finance rules and expectations. These include:

  • “Significantly greater flexibility for commissioners to determine the duration of the contract they wish to offer, within the framework of national guidelines and regulations on procurement, choice and competition.” Guidance claims the “standard contract enables innovative contracting models such as the prime provider approach; with increased flexibility on contract duration, together with new tariff flexibilities”.
  • Spending of proceeds from the marginal rate emergency tariff rule must be used “to reduce pressures on A&E departments over the winter” and “the acute trust must be satisfied the plans for the use of that money addresses their needs”.
  • Taking into account rising demand and the 2015-16 mandated pooled budget with local authorities, commissioners will face a 9 per cent efficiency requirement over 2014-15 and 2015-16.
  • In 2014-15 CCGs will be required to spend 2.5 per cent of their allocations non-recurrently – compared to 2 per cent in recent years and in 2015-16. Of the 2.5 per cent, 1 per cent should be used for “transformation of local services… to prepare for the introduction of the better care fund [2015-16 pooled budget]”.