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

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The week in new care models

This week we have mapped 15 sites funded by the NHS new care models team to develop new forms of primary care, outside of the vanguard. The “primary care home” model is being promoted by the National Association of Primary Care, but has convinced the Forward View leaders to invest £500,000 in trialling it. The model is not unlike the multispecialty community provider one, but operates on a small population – around 30,000-50,000, compared with 190,000-odd for the average MCP.

NHS England has been accused of being all mouth and no trousers on developing at-scale primary care

Building a PACS – a detailed look

A couple of weeks ago I wrote at length about how it is a good idea to avoid fretting about organisational form– because it distracts from efforts to make the existing system work better.

However this week’s briefing is entirely about organisational form.

The people at the Nuffield Trust have helpfully uploaded slides and videos from their recent summit. I’ve been reliving the session on new care models. Here it is.

Highlights include an exceptionally detailed talk and set of slides by the Principia/Rushcliffe multispecialty community provider vanguard, but I’m going to focus on the work of South Somerset’s Symphony Programme vanguard – the primary and acute care system vanguard centred on Yeovil.

If you watch the video, the best bit starts about 21 minutes in, when Jeremy Martin, the Symphony project director, sets out how the vanguard’s new PACS provider organisation will be constituted.

It’s the most detailed presentation on PACS organisational form I’ve seen so far.

Organisational form is particularly important to the development of PACS because they are supposed to be providers spanning primary and acute care. Currently, those services are mainly provided by independent GP practices and publicly owned NHS trusts and foundation trusts.

In order to set up a PACS, you have to integrate GP practices, and crucially their patient lists, with acute provision. Although a very few trusts do run a small number of GP practices, it has never happened at scale before.

The average GP list size is about 7,000. A PACS population of 210,000 would be within the “normal” range, while giving me a nice round number of 30 GP practices serving that population.

Any 30 GP practices will be enormously variable in terms of their size, how well they’re doing financially, how good their facilities are, whether they can attract staff, and in the quality of care they offer – in short, how viable they are as businesses. They will also be run and owned by people at varying stages of their careers, with different values and priorities, and different feelings about how and whether they should develop in the future, and different relationships with the acute sector.

There is no way on earth all 30 practices in our notional PACS will want to do the same thing at the same time. So in establishing a PACS it will be necessary to have different options available to practices. If there is only one way for a practice to get involved, it risks excluding those who it doesn’t appeal to.

That’s why South Somerset is interesting. It has one option for GP practices who cannot continue in their current form, and another who wish to be involved while remaining independent.

For practices that want to give up their partnerships, the Yeovil acute trust will set up a new company to run the general medical services or personal medical services contract, and employ GPs on a salaried basis. The company will be run by a mix of GPs and hospital bosses. Those that go this way will be called “integrated practices”.

For the rest, the vanguard is creating another vehicle, called South Somerset Primary Healthcare. It will be owned by the GPs in these “participating practices”, which will retain their GMS and PMS contracts.

The two new companies between them will own a third new entity: the “integrated accountable care organisation”. Add IACO to your directory of vanguard-related acronyms.

This will be the budget-holding entity that – it is intended – will be given a single, seven to 10 year outcomes based budget for the whole population. The ACO will subcontract services to GPs, social care, and the local trusts.

It is worth looking at the slides here, mainly for the extremely pleasing, legible and symmetrical organogram setting out the new PACS structure.

Mr Martin also outlined three conundrums that need to be solved:

  • VAT – creating new provider entities could create a new tax liability, inflating cost in the system. I’ve heard this issue raised elsewhere, but am yet to hear a solution to it.
  • The return on investment lag – the new model of care will run at a loss for the first three years or so, before the presumed (and only presumed) savings kick in. This underlines the point that, while new care models may help the NHS be sustainable in the long term, they won’t contribute much if anything to the efficiency requirement for this parliament.
  • Regulation – who is the regulator for these new kinds of providers? Steve Field and David Behan from the Care Quality Commission were present and keen to reassure Mr Martin that services would be regulated, but the point is more about whether NHS Improvement will have a remit to oversee these new entities. If not them, then who?

Readers’ comments: transformation funding

There was a lively comment thread on my story last week about the new care models team’s new approach to handing out transformation funding. In essence: not everyone will get much – it looks as though the most promising places will get the most.

A couple of commenters decried the “Darwinian” approach, although I’m not sure that the alternative – to invest in vanguards the centre has less confidence in – is any more attractive.

A couple more comments: “The truth is the centre does not have a robust plan for how the NHS will rebalance and things like vanguard are but one endeavour to clutch at something that might offer some hope.”

“Transformation my eye. The cost savings are bobbins and take years of cultural change to get clinicians in the community to fundamentally change behaviours and develop different relationships. There’s no silver bullet, quick fix or big idea that will do this in one year.”

“The notion that this approach has any chance of solving the huge structural and financial problems facing the NHS is nonsense. And therein lies the problem, because NHS England is betting the farm that the best Vanguards will work and then the rest of the NHS can copy the successful models.”

I hear these arguments often enough, and they reflect a bit of a communications failure around the Forward View, which is unnecessarily harming its credibility among some readers. The point of new care models is not to save a lot of money between now and 2020.

The national bodies don’t expect the vanguards or the wider rollout of new care models to contribute much to the £22bn efficiency requirement. Rather, the point is that they point the way to a sustainable NHS beyond 2020.

Any other business

I’m going to skip next week’s newsletter because of the long bank holiday weekend, so I’ll be back in two weeks with what I hope will be a bumper edition of this briefing.

As ever, keep in touch – I’ll be pleased to hear any feedback, and as above, I’ll include as many responses and comments from readers as I can. So please let me know what you think.

David Williams, senior correspondent, integration