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

  • Strangely, the Department of Health’s long-awaited guidance on the effect of new EU procurement rules on the NHS did not arrive during the referendum campaign. Over a week on, we’re still waiting. But while you wait, competition expert Andrew Taylor has blogged on the impact of Brexit on competition in the NHS. In short: as long as we retain access to the single market, there won’t be very much impact on the health service.
  • I’ve been publicly sceptical about devolution in the past, but one of the many impacts of the EU referendum has been to clarify and strengthen London’s “imagined community”. The cultural and economic differences between the capital and the rest of England are now pretty impossible to ignore, and the new mayor Sadiq Khan is pressing for more autonomy. Although his speech last week didn’t overtly mention the NHS, the press release attached to it did. “It is understood that Mayor is looking for the devolution of fiscal responsibility including tax-raising powers, as well as more control over business and skills, housing and planning, transport, health and policing and criminal justice.”
  • The “working together” vanguard (I assume quality of nomenclature was not a factor in deciding to award vanguard status) is setting up a joint board covering its seven members spanning south Yorkshire and beyond. They’re already collaborating on back office: might they be able to go the whole way and take some tough decisions on what gets provided where? A rule that 75 per cent agreement is needed on a change suggests that they are willing to forego their individual vetoes to make reconfiguration happen. And, it seems that in setting up a common board, they are edging towards a chain type governance structure.

The ‘underarching’ partner and the art of charming GPs

The breakup of Southern Health Foundation Trust needed to happen and may not have concluded yet. It is right that the immediate focus has been on making services safe, but there are implications for new care models too – specifically the multispecialty community provider that is under development in Hampshire.

Specifically: what are we to make of the decision to focus the chief executive’s role onto strategy and development, rather than day to day operations? My feeling is this only makes sense in the context of new models of care, and what we’ve learned recently about hospital chains.

Corporate maturity in primary care

An important live question for MCPs is, what kind of organisation is best placed to hold an MCP contract? A concern I hear repeatedly is that very few if any scale GP providers or GP federations have managerial experience or the organisational heft to bear responsibility for a budget that would cover much of the total local healthcare spend, amounting to tens or even hundreds of millions of pounds. Giving it to even the biggest primary care provider would multiply its turnover by an order of magnitude, and that’s viewed by many as unacceptably risky.

A couple of possible solutions are floating around. Alliance contracts, held jointly between the primary care provider and community service trust, might prove to be a workable fudge. But another option is for an MCP to be composed of two partners: a large organisation to hold the contract, and a more nimble clinically led provider arm to run the services.

The ‘underarching organisation’

One inelegant phrase I have heard for this arrangement is the “underarching organisation” – an entity with sufficient ballast to handle the MCP contract, that potentially sits beneath the practical, clinically led end of the MCP. This could be a community provider trust. But it needn’t be: could it be a private sector organisation with a big enough turnover? This option would be controversial for all the usual reasons, but might make accessing capital easier, in a likely context of ongoing fiscal restraint.

There’s another reason why an MCP might need a bigger organisation than can be created by GP practices clubbing together. A few MCPs believe it will be necessarily for them to take ownership of some local private finance initiative deals, which otherwise will provide an unhelpful acute-centric fixed point in their local health economies. Trouble is, PFIs come with an expensive long-term liability. Transferring that liability to the MCP, to enable it to rearrange services according to the new care model, is only really possible where MCPs are backed by a trust or other big business.

MCP chains? 

Going back to Southern Health, where have we heard about a chief executive focused on strategy rather than ops before? A couple of weeks ago I sketched out the proposed governance structure for a hospital group or chain, where there would be a strategic executive sitting across the whole group, while individual hospital sites have their own mini-boards that are responsible for actually running the services day to day.

I’ve not heard it put quite like this, but you can see how several MCPs could sprout up out of a single community trust (or big private company). If you wanted Hampshire to have more MCPs to cover the rest of the Southern patch (I have no special knowledge – it’s just as handy an example as any) the model would already be there locally, ready to replicate.

About that MCP contract…

NHS England has been planning to put out a big policy document on MCPs, setting out what an MCP is and what one isn’t, what the contract will look like and a load of other helpful stuff since at least May. Apparently it’s now coming out by the end of July.

But versions of it are circulating, and to judge from his presentation at the Health+Care conference in London last week, Chaand Nagpaul has been briefed.

Credit goes to my primary care specialist colleague Rebecca Thomas for this bit (she also provided the point about PFI, since I’m being honest), because she was in the room, not me.

It sounds like there might be some compromise options being inserted to avoid scaring off GPs, and allow MCPs to get going sooner rather than later.

For instance, from Dr Nagpaul’s slides it looks as though the GP listed population covered by an MCP must be 30,000 or more. Most vanguard MCPs are over 100,000 population, at least in theory. The smaller minimum means some MCPs will be suboptimal in size at least to begin with, but it means they can get going even before all the GP practices who might eventually get involved decide to finally take the plunge.

There are also a few options emerging for GPs who want to sign up: they can be employed by the MCP directly, or retain their PMS or GMS contracts if they prefer. And, they can have a “return ticket”, so they can go back to GMS if they decide they don’t like being in an MCP.

This might make the difference between a practice deciding to come in or hold out for another few years.

Again, it’s not neat, but again it is realistic. And again, the message to everyone planning to adopt this model of care is clear: don’t wait for it to be perfect - get started now.