Tracking everything that’s new in care models and progress of the Five Year Forward View, by integration reporter David Williams.

The fortnight in new care models

I’ve been away for a couple of weeks so there’s a bit more to round up than usual.

  • South Warwickshire Foundation Trust – not a vanguard but an interesting organisation on the quiet – has proven that Salford doesn’t have the monopoly on bold moves towards integration. SWFT is the main community services provider for the county of Warwickshire, and has announced it is to take on 170 social care staff from the county council. The social care workers will integrate with SWFT’s intermediate care team to launch a “HomeFirst” service, aimed to ease the hospital discharge process, respond to crises in patients in the community and promote independence and continuity of care. Encouraging stuff. I wonder if SWFT might have been emboldened by the recent and sensible decision by commissioners not to put their community services out to competitive tender?
  • Dudley CCG, whose progress towards setting up a multispecialty community provider got me excited just before I went on holiday, appear to be pioneering a new model of provider/commissioner dispute to go along with their new model of care. Two points here. First, the MCP may forge ahead but the old structures and accountabilities still apply elsewhere in the local system, and for all the positivity about vanguards, the knock-on effect has yet to play out properly in most places. Second, the acute trust, which stands to lose out, says it intends to bid for the MCP contract. But why not just do a PACS then?
  • Yeovil District Hospital – a prominent PACS vanguard – has had an unflattering report from the Care Quality Commission. It’s good in parts but requires improvement in more areas, including in the “well led” domain. The trust’s board was praised for being approachable, but wasn’t aware of all the risks that existed in the hospital and challenge was not sufficient. The trust is in a bit of mess financially too. Yeovil has previously set the pace for establishing a workable structure for a PACs, so it will be interesting to see whether criticism from regulators will hold up their progress.
  • NHS Improvement has issued a “frequently asked questions” document about new care models. Many of the answers amount to “we’re working on it”, but the things the regulator is working on do sound interesting: a range of assurance and regulatory tweaks; more thinking on governance structures; new contracting models. Importantly, NHSI is considering whether some regulatory work will be done at “business unit” level rather than being directed at the top of the organisation – an important issue facing hospital chains. The document also includes an answer to the question: can a GP federation become a foundation trust? The answer is no, but it’s very interesting that people are asking.
  • Ben Gowland, ex-clinical commissioning group chief and now an independent consultant, has been reading the multispecialty community provider framework (on which there is more below), with a keen eye on what it means for GPs. He writes: “The overriding question I am left with is where do the incentives lie for general practice? Maybe the model of an MCP, with its focus on population health and freedom to innovate, will be attractive enough for some… maybe it will be the only way to access the additional £2.4bn general practice has been promised and needs to survive.”
  • Perhaps part of the answer to Mr Gowland’s question can be found in an article published on NHS England’s website, about what it means to be in an MCP. The authors are Nick Harding, Sandwell and West Birmingham CCG boss; and one of the key figures in Modality, and Nigel Watson, a leading light in the southern Hampshire vanguard. As policymakers explore how to attract GPs into MCPs, there is an important theme relating to risk: GPs will not want to give up their guaranteed GMS or PMS contracts if they see becoming part of an MCP as being less secure. The specific risks lie in 1) part-owning a provider organisation that could fail, or lose its contract in the future; or 2) in being less secure as an employee of an MCP than they would be in than clinging onto a GMS contract until they retire. This is why NHS England and the Department of Health are working on changing the legislation governing GP contracts to allow them a “return ticket”, which could enable them to chuck their lot in with the MCP, but still go back to GMS if they find they don’t like it.

MCP procurement and the art of keeping GPs onside

Because there’s been lots to say about the world at large, this section will be a shorter than normal main feature.

The main event for me to catch up on after a couple of weeks off was the publication of the emerging MCP model and contract framework.

In the absence of any definitive guidance from the DH, this document gives us a little more clarity on the issue of procurement for new care models.

Correctly, the document emphasises the importance of getting the model right first rather than rushing into a tender:

“An MCP cannot simply be willed into being through a transactional contracting process. Merely rewiring institutional forms, contracts and financial flows changes nothing. By far the most critical task in developing an MCP is to get going on care redesign…”

However, an MCP can’t be sustained on goodwill alone – a model reliant on relationships is only as resilient as the individuals who are making it work: eventually new contracts and organisational forms will be needed to support the MCP for the long term.

What then?

Commissioners are going to have to at least issue a prior information notice in the Official Journal of the European Union.

But that will not necessarily lead to a long competitive procurement with an uncertain outcome. There are a number of ways clinical commissioning groups may be able to control this process.

For example, the advert in the OJEU could “make clear that the CCG is open to options that involve partnering between different organisations (including incumbent providers and potential new providers)”. CCGs should also “encourage prospective bidders to engage with GPs and vice-versa”, and explain that “all prospective providers would be asked to demonstrate that they could command the support of the local GPs”.

CCGs can’t automatically name local GPs as the preferred provider, but they can give GPs quite a lot of power over which bids are credible and which aren’t.

A CCG can also set an expectation that the winning bidder would have mobilisation plans including subcontracting with other providers.

In a further apparent concession to GPs – and to the reality that incumbent providers can’t just be replaced with an alternative and therefore the new model must be developed with their consent – CCGs can designate “particular parties as nominated subcontractors to the MCP” organisation for specific elements of the contract, regardless of who wins the overall contract.

So while there is a clear recognition that the law cannot be avoided, it appears it can be complied with at the same time as ensuring the people who need to be engaged are able to be.

Unsurprisingly, later this year NHS England intends to publish further guidance for CCGs, whose members and many of whose leaders are local GPs, on managing conflicts of interest.