Essential insight into NHS matters in the North West of England, with a particular focus on the devolution project in Greater Manchester. By Lawrence Dunhill

Thwarted ambition

The spirit of devolution led Greater Manchester to crank up its ambitions for creating new care models but – perhaps inevitably – some of the region’s key structural reforms have been thwarted.

Leaders in Stockport and the city of Manchester had sought to create single organisations to hold accountable care type contracts encompassing NHS community services, primary care, social care and mental health.

But the barriers have become more solid over the last 12 months, and have probably prevented this happening in anything other than the long term.

In Stockport, the idea was to re-engineer the governance of the foundation trust so GPs and council officials could be represented on the board and council of governors, and for this new form of FT to hold the contract.

There appears to be no legal barrier to doing this, so the fact the planned procurement process has been paused for several months is likely to be down to more familiar issues.

Even with a promise of board representation, any arrangement in which GP contracts are passed over to an organisation that delivers acute care would be a huge leap of faith for the doctors.

GPs have been nervous of this type of scenario since the birth of the NHS, and extracting an ultimate agreement may well prove elusive.

There will also be concerns about the durability of Stockport FT, which has persistent problems with finances, quality and performance. A recent CQC inspection report painted a worsening picture with the urgent and emergency services rated inadequate.

The trust is probably not seen by regional and national leaders as the best testing ground for a radical new care model.

The barriers in Manchester are more technical.

The idea was to form a new organisation, such as a joint venture company, that could be jointly owned by the NHS trusts, council and GP federation.

The first problem is there are laws, which don’t apply for NHS trusts because they get bailed out, against a subsidiary or joint venture company trading while insolvent, and given the current financial challenges, the risks of this would be real and significant.

VAT liabilities and exemption rules present another problem, as these are applied differently between NHS trusts and private entities when it comes to subcontracting services from suppliers and could result in additional charges. This proved to be one of the major issues with the disastrous UnitingCare contract in Cambridgeshire.

Meanwhile, any attempt to get around the insolvency or tax issues by creating a new form of NHS trust to hold the contract will have been scuppered by the simple fact it could not be jointly owned by GPs, which seems to be one of the key conditions.

Presumably Manchester didn’t go down the Stockport route of a re-engineered FT because this would have struggled for support from the doctors.

Good groundwork

It is still possible for good progress to be made on the ground, of course, regardless of the thwarted organisational work.

Multidisciplinary teams can still be created in the neighbourhoods, and efforts made towards effective integration through an alliance contract or similar arrangement.

But there are dozens of other areas in England in the process of doing this. Some will do it well, some won’t, but we’ll only really be able to judge once we start to see the impact they are having on acute activity, costs and outcomes.

What made the Stockport and Manchester projects stand out was their radical proposals on organisational form. Without them, they have lost their gloss

Alternative approach

Over in Salford, they are probably glad that they didn’t go down the multispecialty community provider contract route, which was devised by NHS England to help persuade GPs to sign up.

Instead it opted to get on with what was immediately possible by making Salford Royal FT the prime provider for all adult health and social care services.

Last year, 450 of the council’s social care staff transferred to the trust (Stockport and Manchester still seem a long way off from doing this), which now acts as the commissioner for mental health and is responsible provider for domiciliary and nursing home care.

The downside to this approach – expressed widely a couple of years ago – was it would be difficult to persuade GPs to be employed or agree to new contractual forms when the project would appear to be centred around an acute trust.

This will still be an issue for Salford, but for all the efforts in Stockport and Manchester to involve GPs in the plans and build an organisation around them, it looks like they will end up in a similar place.

Burnham’s big idea

I won’t be holding my breath before the autumn budget, but Andy Burnham’s proposal for Greater Manchester to be a pilot area for the reform of social care funding is surely worth some serious consideration by the Treasury.

The mayor has revived his call for social care to be fully integrated with the NHS, to make it free at the point of delivery, and funded through a form of wealth levy.

The Conservatives were bitten hard when they raised the thorny issue of social care funding in the election campaign, and will be extremely cautious about reviving it.

But as Mr Burnham says, something has to give, and the devolution project offers a handy testing ground.

Kirkup is coming

I’m told that Bill Kirkup’s review of governance and care failings at Liverpool Community Health Trust is almost ready to be published.

This report has the potential to be explosive, and could point fingers at those who were commissioning and regulating its services.

Some of the worst examples of poor care are likely to come from the Liverpool’s prison health services, which were previously run by LCHT.

Lancashire Care FT took on a five year contract for the services in 2015, commissioned by NHS England, but serious problems have persisted and it now wants to bail out early.

The trust also recently decided not to bid to renew its prison contracts in Lancashire, which begs the question as to whether these contracts are viable.

One key reason that mental health has long been neglected is that was for national leaders and budget holders to ignore. This effect is surely multiplied when it comes to prison healthcare.

North by North West takes an in-depth fortnightly look at one of the NHS’s most challenged and innovative regions. There will be a particular focus on the devolution experiment in Greater Manchester, but my scope also includes Merseyside, Lancashire, and Cheshire.

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