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

The week in new care models

Can the vanguards manage without most capable provider?

“Most capable provider” was good while it lasted.

The method – under which new contracts can be awarded without open competition – emerged with the blessing of Monitor a couple of years ago, as an alternative to a full-blown tender. For some commissioners, it has offered a practical way to comply with procurement rules while collaborating with existing providers to redesign services and contracts.

Now, just as it was starting to catch on, it appears to have been killed off by a new tranche of EU procurement rules.

Last week I set out how these new rules give commissioners a new duty to publicly advertise all contracts, rather than jointly design service changes with an existing provider.

The effects are already being felt, and can be seen in evidence given to the Commons health committee. The EU regulations kicked in for councils a year ago. In Somerset, the fear of falling foul of the new rules has prevented the council from rolling social care into a proposed joint commissioning project.

The key word there is fear. Would the council have been challenged in the courts if it had not put social care to competitive tender? We don’t know, but the possibility of that happening is as important an influence on commissioner behaviour as the letter of the law. The notional risk of an expensive and embarrassing legal challenge that prevents or delays change taking place will be enough to cause other commissioners to change their behaviour.

The select committee also heard that Monitor had told the CCG that the most capable provider approach “is not available to NHS organisations after April” thanks to the new rules.

National guidance to the same effect would be welcome. National leaders have been oddly quiet about all this so far.

We should remember that most capable provider was a workaround which answered anxieties around an earlier set of procurement rules. It is conceivable that ways around the new EU rules will also be found. If they are, they should be publicised sooner rather than later.

But if it does turn out that most capable provider has no future, what are we losing?

In one sense, we’ll never know because it is too early to chalk up any definite success stories from the policy.

However, note what has happened in Oxfordshire over the past couple of years: a long term adult mental health contract was awarded last autumn to a consortium led by the existing provider. The process succeeded where an earlier competitive one failed, in part because it recognised that change is best achieved by building trust, and that there is no point behaving as though there is a mature market for providers when for many services there is not.

The method seemed to be tailor made for vanguards, where commissioners and providers have been told they have a mandate to collaborate.

Interestingly though, one vanguard site this week announced it had entered into an innovative new arrangement via a competitive process.

Tower Hamlets Clinical Commissioning Group has made local GPs the “prime contractor” for community services. Under this intriguing arrangement the borough’s GPs – in the form of the CCG – are delegating their responsibility for integrating and improving community care to themselves – in the form of the local GP provider company. It aligns community services and primary care, which is exactly what this new care model is all about.

A competitive dialogue process was used to award the contract. Excitingly, some of Cambridgeshire’s worst mistakes are not being repeated: although savings are expected, there will be some extra cash available over the first year or two while the expected efficiencies are realised. And, commissioners believe services should be redesigned in chunks, rather than attempting to transform too much at once. This approach is intended to avoid inflicting too much uncertainty and disruption on too many staff members, and recognises the limited capacity and capability of the CCG.

Still, there are two reasons why Tower Hamlets doesn’t necessarily solve everything: First, the whole process took two years – a fairly standard timeframe for big procurements, but one which would delay the implementation of the Five Year Forward View if everywhere else had to do the same thing.

Further: Tower Hamlets had to keep its procurement process and vanguard work separate. This raises the possibility that in other places tenders could deliver results that do not fit new care models so neatly.

Ambiguity over how procurement rules relate to new care models has given vanguards space to experiment and begin setting up new arrangements – but it cannot last forever. Soon, national leaders will have to give the wider NHS a clear steer on how they should go about commissioning for new care models.