What's New in Care Models: Prepare for national rollout

In our first editorial of the year we highlighted two reasons why 2017 won’t all be gloom: the likely expansions of the care home vanguard model, and of primary care home.

Expect movement on this soon.

It is likely there will be a fairly serious chunk of money for both models spanning the next two years, and an approach from the centre that says, “If you want to do this, we’re ready to contribute” – inviting people to come forward when they are ready, rather than imposing from above. The aim will be to support everyone in the country, if they’re willing to adopt the model.

National leaders are excited by what the “care home six” vanguards have been able to do so far and put out guidance last year setting out the model and how it can be adopted anywhere.

When the announcement is made, it will be the most significant vote of confidence in any of the Five Year Forward View care models so far.

Primary care home: the next phase

The expansion of primary care home should surprise no one. Simon Stevens has already said he believes GPs are hungry for change and willing to embrace new ways of working because “their backs are against the wall”. Late last year he strongly indicated that primary care home was where the action would be over this next period. And, he’s subtly indicated a timeframe for reform: primary care transformation will be “won or lost” over the next two years.

How much money will be devoted to the model hasn’t been confirmed yet, but the initial sites, pioneered by National Association of Primary Care, were given about £1 per head of population. That would scale up to about £50m to cover the whole country.

The PCH model was developed to improve the quality and experience of primary care both for GPs and patients. It wasn’t explicitly designed to be the basic building block for multispecialty community providers or primary and acute care systems, but that is how many now view the model.

A vital call NHS England has to make is on the financing of PCH: should PCH sites be incentivised to do things that the centre wants them to do – such as cut prescribing costs, reduce hospital admissions, and provide more community services? That isn’t the main purpose of the model, although it is the explicit aim of most sustainability and transformation plans, which also generally want to establish PCH-style extended GP “hubs”.

If as seems likely, PCH sites are given some sort of contracting incentive which falls short of a share of full capitated “hard budgets”, the arrangement will resemble the practice based commissioning of the second half of the last decade. This is a moment of circularity for the NAPC, which has its roots in the hard budgets era of GP fundholding and later became one of the big champions of Andrew Lansley’s early proposals for “GP consortia”.

And then what happened? In the process of rolling it out nationally, the policy ossified into a shape that GPs didn’t much like the look of, and which didn’t have many of the advantages of the original model: clinical commissioning groups.

There’s probably a lesson for today somewhere in there. There is also an enjoyable irony that the NAPC’s current ideas, which are not that different to their earlier ideas, are being incorporated as part of the solution to the fragmentation brought about by the 2012 Health and Social Care Act, which they were so close to the genesis of.

The most investable proposition available

The context to all of this is the forthcoming refresh of the forward view, which will take stock of progress to date and set realistic goals for the next two to three years. At least, that’s what it would be, if the context to the forthcoming refresh of the forward view were not what might politely be described as a financial and political horror show.

With NHS England and Number 10 having begun 2017 with a row about whether the latter really had provided the former with all the resource it asked for, there is a risk that the refresh will become all about the money.

That would be a pity because the vision for new models of care was every bit as important to the forward view as the now discredited financial projections that underpinned them.

It was announced just before Christmas that NHS England is continuing to support the original new care model vanguards – for one more year at least. They get about another £100m for 2017-18, allocated pretty much as it was this year.

It’s encouraging that budget holders at NHS England remain committed enough to transforming care, even in the most grisly part of the aforementioned horror show, to spend more than last year on new care models.

But it’s also significant that, if there is a bit more cash available, that the extra isn’t going on a new wave of PACS sites, for example, or giving MCPs a bigger proportion of the transformation funding they said they needed.

They have not done that – instead, in the coming weeks we are likely to have confirmation that national leaders see primary care home and enhanced health in care homes as being the most investable proposition available.