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

  • How are sustainability and transformation plans coming along? Nigel Edwards of the Nuffield Trust has been talking to leaders representing about a third of them. He sounds this note of caution on new care models: “The assumption that integrated care, ACOs and demand management can deliver savings is simply not supported by the evidence; and more caution is needed about both scale and timing than some plans allow for.” Some of the implications of this commitment to new care models, which are still largely untested in the NHS, are explored below.
  • One area that, in spite of Mr Edwards’ warning, is explicitly developing a new care model to help solve a financial problem is Oxfordshire. The CCG, which has an unforeseen deficit and rising demand, is knocking heads together after its two main providers failed to integrate care on their own. The CCG doesn’t mention multispecialty community providers overtly, but the MCP policy framework is the most useful lens to view this through: the CCG has stated a preference for any bids to involve the local GP federations. Cannily, Oxford Health (the local community trust) has announced a plan to set up an MCP and jointly bid with the GPs, potentially isolating the acute trust, Oxford University Hospitals. Two observations: first – if this is the soil they’re growing the new care model in, I’m worried it might be mildly poisonous; and second – given rising demand is busting the CCG’s budget, what sane provider will want to take on the financial risk? The spectre of Cambridgeshire floats once more into view…
  • NHS England has published better care fund performance data for quarter three of 2015-16! At this rate we may know whether year one of the BCF was a success before Christmas.
  • A couple of weeks ago I highlighted an NHS Improvement document which revealed the time-limited nature of the vanguard programme. On Twitter, Ilana Lassman points out that the document has been re-drafted to remove the reference to the vanguard programme ending in 2017-18! Good spot… I did hear that some in and around new care model world felt the original drafting had been somewhat “loose”. The facts haven’t changed though – the vanguards get three years of direct transformational funding, ending next year, then it’s up to STPs to drive new care models.

Catching penguins

The new care models programme is steaming ahead in all sorts of interesting ways all over the country.

But the faster it goes, the bigger and more urgent becomes the challenge to the arm’s length bodies, whose job increasingly resembles that of Gromit the dog clinging to a runaway model train, desperately laying down track in front of him to avert a derailment.

Poor Gromit eventually manages to catch a villainous penguin in a milk bottle, but not before his train has smashed into a kitchen cabinet door. The NHS arm’s length bodies have a rather different job: designing an operational and regulatory framework that enables new care models to thrive nationally.

The ALBs have a terrifying number of penguins to catch. This week, I’m going to detail two.

The first penguin is concerned with constructing an assurance process for accountable care organisations. Can NHS Improvement come up with a system for making sure that an organisation planning to become a primary and acute care system or MCP – possibly a new joint venture company, social enterprise or limited liability partnership – is robust? National leaders are desperate to avoid another Cambridgeshire debacle. If we are to have PACS or MCPs fully up and running by April 2017, which is what some vanguards want to do, they’re going to have to start going through the assurance process pretty soon, and that means national bodies are going to have to decide what that process includes.

(This is a much bigger and riskier penguin than the one pertaining to hospital chain accreditation, which the ALBs successfully caught last week)

The second penguin is about “mainstreaming” new care models: expanding them from vanguard sites covering a fraction of the population to covering at least half of England by 2020.

It has now been spelt out that the vanguard programme will finish in its current form at the end of 2017-18 – and the STP process will become the main vehicle for implementing the new care models bit of the Five Year Forward View.

Gromit

Gromit

Essentially that means severing the direct link between centrally controlled transformation funding and the 50 vanguard sites.

Optimists hope there will be some transformation funding in 2018 and beyond. But, it will be aimed at supporting the development of new care models more broadly around the country, and it will be up to STPs to make the case for investment and to ensure it bears fruit.

This crystallises the gigantic leap of faith the service is being required to make regarding new care models: the process of “mainstreaming” will begin before the vanguards will be able to fully demonstrate their effectiveness – investment in vanguards so far has assumed a five-year return on investment timescale.

Nevertheless, 90 per cent of STPs are understood to include something PACS or MCP-like. Given that the programme was always supposed to be about implementing the forward view universally, it is more surprising that four or five of them aren’t planning a new model of care. Still, most of the 90 per cent will not have well developed plans and will need support if they are to have a reasonable chance of becoming reality.

For new care models to be mobilised on that scale from a standing start, NHS England’s operations directorate, which the STPs are answerable to, is going to have to take ownership of the new care models agenda.

That part of the authority was originally set up to establish then oversee the commissioning system, to directly commission some services, and to manage delivery on performance and finance. In the future, the ops directorate will instead have to set the pace for transformation, and assist the implementation of it via its regional and area teams – the problem being that the people who know best how to make it work will either be in the central new care models team, or scattered across England in the vanguards.

The ops directorate’s old role – along with the entire “commissioning system” as originally envisaged – is becoming ever-more irrelevant as the forward view is implemented. And, April 2018 is still far enough away for this shift in purpose to not feel completely impossible.

But it is still a tricky penguin to catch, especially given that the derailment NHSE and NHSI are most preoccupied with averting this year is the financial one, not the one that happens if new care models don’t succeed.