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

I remain keen to include as much feedback, reaction and debate in this weekly briefing as possible. To that end, this week’s main feature is entirely driven by reaction to the main subject of last week’s newsletter. Got something to say about new care models? Contact me.

The week in new care models

  • An NHS trust is entering the home care market. Northern Devon Healthcare Trust will be the prime contractor for domiciliary care in some parts of the county. Plans have now been approved by all relevant boards. The trust won’t be directly providing services, but it will now be able to “influence the quality of care given outside of its hospitals and ensure providers are working to support patients’ ability to live independently”.
  • South Warwickshire Clinical Commissioning Group has scrapped its controversial plan to competitively tender community services. The CCG has instead decided it had better work jointly with the two other NHS commissioners in its sustainability and transformation plan patch on the redesign. This is sensible, although less than a month ago the CCG told me its procurement exercise was completely in keeping with the STP, so obviously a change of heart has been had. Warwickshire North, one of South Warwickshire’s STP partners, was in the middle of a non-competitive process using existing providers. At the time of writing we don’t yet know what approach the CCGs will take.
  • There were several reasons to be disappointed by the long-awaited “GP rescue package” launched last week by NHS England. Principally: that it has precious little to say about reform, and as we know, transforming primary care is the foundation of the new care models set out in the Five Year Forward View. My colleague Dave West has written at length about this so I won’t rehash his points here. All I would add is: it is clear that the first order priorities for the NHS this year are sorting the finances and steadying the ship. The national message appears to be that large scale reform is something to think about once those jobs are done.
  • What little the GP package does say about reform links to the multispecialty community provider/vanguard agenda. There’s going to be a new voluntary GP contract to provide extended services. This is the MCP contract, being developed nationally as part of the vanguard programme and which will be introduced from April next year. Six areas are expected to take it up. They haven’t been named yet but you could guess at least three likely contenders. Who will hold these contracts? GP federations, private companies (ownership unclear) or joint ventures with local trusts. So what role does NHS England envisage in a reformed system for the traditional practice?
  • Our sister title LGC reports that five CCGs in Yorkshire – including two in vanguard areas – are reducing the amount they pay into their Better Care Fund pooled fund. The vanguardistas in question are Harrogate and Airedale. The latter is especially surprising because it is an enhanced health in care homes vanguard – the ones that explicitly focus on better working between council and NHS commissioned services. Airedale’s CCG has withdrawn over £400,000 that it was previously contributing to the BCF over and above the minimum requirement. Bradford council says the move will make it harder to support discharges from hospital. At the very least this demonstrates a lack of confidence from those CCGs that the BCF is the most effective way of using NHS funding to support integration.
  • And LGC reports that Cambridgeshire County Council and Peterborough City Council are pushing for a joint devolution deal, rather than being part of a bigger East Anglia bid. Aligning devo to NHS STPs makes sense if you want to align health and social care commissioning.
  • Local government expert Phil Swann writes about the tension between NHS England’s increasingly muscular, top-down approach to local system planning through the STPs and the emergence of some health and wellbeing boards as effective leaders in some areas. “This is being done in a way which pays no respect to the effort that has gone into the development of boards by local councils and clinical commissioning groups,” he says.

Can conflicts of interest be avoided?

Last week I reported that Tower Hamlets CCG had awarded its community services contract to a community interest company owned by local GPs.

The story attracted a lot of interest online, including a lively comment thread.

There were four points that came up repeatedly: congratulating the CCG for its innovative approach; doubting the deal will generate efficiencies of about 8 per cent; concerns over the complexity of the new system; and worrying about conflicts of interest.

Here are some examples:

  • “One can only hope that they really know what they are doing. Procurement is not the same commissioning. Hard to see how a more complex contractual deal will save up to 8 per cent of provider cost. Too many CCGs treat commissioning as if they were buying office consumables.”
  • “This is more complex managerially than current arrangements, and lines of accountability will be tricky regarding delivery of KPIs and associated apportionment of benefits/penalties.”
  • “Hard to see how real savings will be delivered, especially since community services costs are almost all staff – which posts will be eliminated as a result of the anticipated improved efficiencies?”
  • “I wonder how the CCG board handled the conflict of interest involved in awarding a major contract to its own board members.”
  • “People are right to be cautious, concerned and cynical. These are all experiments and can all fail badly, costing money and services and disruption with patients or community users (and staff) if they aren’t managed properly or set up correctly.”

With CCG conflicts of interest clearly occupying minds at NHS England at the moment, it is worth setting out how the CCG sought to avoid them.

The problem is that the owners of the winning bidder (Tower Hamlets GPs) are the same people who make up the membership of the CCG. The likelihood is there will be an increasing blurring of the roles of community services and primary care – that’s what an MCP is – and the risk of conflict of interest is so glaring it merits addressing at length.

In Tower Hamlets, the procurement process was essentially outsourced to independent managers, who even went so far as to run the process from a different office because they wanted to avoid bumping into CCG staff or members in the canteen or toilets.

A CCG statement added: “Everybody who was involved signed confidentiality and conflict of interest declarations, and at every meeting they were asked to declare any new conflicts of interest… decisions were taken only by people who were not conflicted.” For example, the CCG said, “no Tower Hamlets GPs were given information or involved in deciding what the contract should look like or who it should be awarded to”.

So GPs, as members of the CCG, had to outsource their commissioning functions to interims, in order to award a contract that delegated the responsibility for community services to themselves – in the form of a borough-wide provider company.

Will contortions of this kind always be necessary to ensure commissioners cannot be accused of being compromised, or is there an easier way?

The points about the extra layers of management come from the prime provider model: the lead provider role sits between commissioner and provider, creating a new tier in the system that doesn’t currently exist.

There is a paradox here: the name of the game has to be designing services that cross traditional boundaries (physical/mental, primary/secondary, NHS/social care). To the patient, this should feel simpler than bouncing around between lots of discreet organisations – so it’s interesting that the governance around so many integrated care deals is more convoluted than what went before.

This Tower Hamlets deal will be a test of whether adding complexity behind the scenes can create more streamlined services. And whether those can bag savings of up to 8 per cent in the cost of care will mean the difference between success and failure for this deal.