Apologies for missing a week last week.

The fortnight in new care models

  • Stockport’s multispecialty community provider vanguard is going to be a bit more than an MCP. Specifically: local leaders are now planning to incorporate significant amounts of acute work into the model, including accident and emergency. They call it an “MCP-plus”. You might as well call it a primary and acute care system, since the dividing line between the two is pretty blurry. It looks like the local foundation trust will hold the main contract and, surprise surprise, GP core services won’t be included to start with (see below for more on this subject).
  • Two vanguard trusts in the North West have taken a stake in a GP practice. Cumbria Partnership Foundation Trust and University Hospitals of Morecambe Bay FT are both involved in the Better Care Together primary and acute care system vanguard – and will now become partners in the practice. An officer from each of the trusts will join the practice’s management team, and the trusts will run the business side of the practice – including IT, workforce, and estates. I wonder if the trusts gave the GP partners money upfront to buy the stake, and whether they are now co-owners of the premises? While this is only one practice, it is an interesting model because it allows GPs to draw on the business capacity of the trusts and align their leadership and decision making, without giving up their independence or funding flows, which few practices seem prepared to do (again, there is more on this in the main feature below).
  • Lakeside boss Robert Harris is lamenting the increasing grippiness of sustainability and transformation plans. He blogs for Reform: “By centralising control (grip), we lose creativity, local ownership and thus the drive to transform ourselves into something leaner and better positioned to succeed. I don’t want to be controlled, I want to be supported to excel. That support is evidenced by giving me room to manoeuvre and sufficient resource to broaden and deepen our services.” Of course there’s more to support than funding, but Lakeside is one of the least funded of the vanguards. Professor Harris continues: “If we are to transform the NHS, primary care needs to be treated differently and taken seriously. Only by broadening and deepening and supporting primary care by giving us budgets can we make the necessary changes.” (Is that going to happen? See the main feature!)
  • Greater Manchester integration continues to accelerate: commissioning chiefs are working on plans for a potential single management team and decision making body for health and social care services across three boroughs.
  • Delayed transfers of care hit their highest ever level in August. The data was released on the day that the Care Quality Commission said problems in social care were directly linked with pressure on the acute sector, and – in a significant and unusual move for the regulator – called for more money for social care. With the NHS on the fiscal naughty step at the moment, HSJ understands there is some very lively lobbying taking place for more money for social care.
  • The “light touch regime” – new EU procurement rules to you and me – has now been live for six months. We’re still waiting for Department of Health guidance on how to navigate them. Perhaps it’s playing for time? None of this will matter by 2019.
  • Devolution! Everyone’s favourite policy shambles staggers on: Norfolk and Suffolk, “Greater Lincolnshire” and Sheffield’s deals are at risk of collapse despite long awaited clarity on the policy from Theresa May, Local Government Chronicle reports.
  • In other policy shambles news, LGC also have an excellent story about the better care fund. Staffordshire and Northamptonshire have both gone into arbitration as clinical commissioning groups and councils fail to reach an agreement. Northamptonshire, you may remember, was one of the areas that had trouble agreeing its BCF back in 2014.

If GPs don’t want full integration, what next?

The King’s Fund has put out the most detailed, considered progress report on the vanguards I’ve yet seen.

It makes for mostly encouraging reading, unless your expectations for new care models are wildly unrealistic: partnerships are being formed; innovations are taking place; they will take time to mature.

What’s interesting is that vanguards the KF studied are already focusing on governance, contractual and organisational forms – and GPs are the sticking point. Chief executive Professor Chris Ham recently wrote in HSJ that this focus is holding up implementation in some areas. This in turn “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”.

As the prime minister continues to insist the NHS got the money it asked for, it is reasonable to assume NHS leaders are being regularly asked by Downing Street whether the future envisaged in the Five Year Forward View is becoming a reality as fast as they expected.

With that in mind, the focus now must be on ensuring as much progress as possible can be made in “virtual” or “partially integrated” PACS sites.

Because from talking to vanguards, places that resemble them and people (like Professor Ham) who study them, it is clear that if the new care models cannot take root until will have “full integration” of primary and acute care, we’ll be waiting a long time.

The King’s Fund report looked at Salford, Northumberland and South Somerset – three of the most advanced PACS vanguards. As regular readers will know, the first two do not include core primary care within the initial integrated/accountable care organisation, or within the single budget that entity will control. As ever, that doesn’t mean there is not plenty of new collaboration including GPs. It just means they’re getting friendly with their neighbours, but they haven’t yet committed to knocking the wall through and moving in together.

In an interview with HSJ following the report, Mr Ham said an integrated budget for everything except core primary care would not be a “total population budget”. But it would be “much closer to that than the contracting and funding streams we’ve had in the past”.

This may be as far as PACS can realistically get while we still have a GMS contract for primary care. Because, as Professor Ham explains, GPs aren’t going to give up their guaranteed income streams.

Call me naïve, but I’m a little surprised by this – given the relentless messaging from GP representatives about how unsustainable primary care is, I thought I might have heard at least some vanguards telling me their local GPs were desperate to be rescued. After all, if you genuinely are in a fatally leaky dinghy you’re not generally too fussy about who is driving the ship that picks you up.

But when it comes to the crunch, in vanguard areas, GPs are at least acting like they still have options. Professor Ham said: “What [GPs] would be happy with is getting as close as you can to a whole population budget by bringing together the other funding streams and aligning GMS or PMS [GP funding] alongside that, but being clear there’s no membrane that allows resources to pass from one to the other.”

NHS England says the same. The PACS policy framework document published last month says: “Discussions with the vanguards have shown that, for now, many GP partnerships wish to retain the option of returning to their GMS or PMS arrangements in future, not least because of the perpetuity of these contracts.”

Professor Ham has also recently said national leaders should hold their nerve and see through the innovations that have been stimulated by the forward view.

Quite right. And, although it’s becoming clear that we’re not going to have very many if any PACSs fully set up by 2020, there is still plenty of work to do to reinvent care in virtual and partially integrated sites. We should not allow the barriers to full integration to become a reason for the wider integration agenda to lose momentum.

What's new in care models: Is full integration impossible?