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
- This week’s instalment of the Cambridgeshire saga: the National Audit Office has announced it will conduct a review of the failed UnitingCare older people’s services contract - something Labour frontbencher Lord Hunt first called for three months ago. That raises the exciting possibility of a Commons public accounts committee hearing into the disaster, and someone without skin in the game reviewing the roles of both NHS England and Monitor-as-was.
- The new chief of the Association of Directors of Adult Social Services has criticised the better care fund, saying it can’t be right that social care is dependent on council officers negotiating with clinical commissioning groups, saying this is like going “cap in hand” to the NHS. “What we really need is to move from the BCF into a much more sustainable whole system health and social care funding regime where we really agree priorities and risk together.” Such a solution is entirely within the gift of local council and NHS leaders – but will have to be negotiated locally. The alternative is a top-down directive from the government, and that wouldn’t be very localist, would it?
- On the subject of the BCF – there is still no quarter two data on better care fund progress forthcoming from NHS England, I am downhearted to report.
- NHS competition expert Andrew Taylor has blogged engagingly about the new EU procurement rules. He doesn’t think they will lead to a lot more competitive tendering. He also gives a plausible explanation as to why national leaders have nothing much to say on the issue. NHS England “can’t explicitly tell CCGs not to bother holding tenders because decisions are unlikely to be challenged. This would be the same as encouraging CCGs to break the law. But, issuing guidance that is consistent with the regulations, and which might lead to a deluge of tendering activity, is probably not the best of ideas either.”
- Vanguards in Greater Manchester will not access the central transformation fund for 2016-17. The fund is expected to be worth around £200m. Greater Mancunian vanguards will instead have to be funded out of the region’s £450m share of the £1.8bn national sustainability and transformation fund. The only exception is the part The Christie is playing in a national cancer vanguard.
- NHS England has released details of how the £200m transformation fund for 2015-16 was spent.
- One vanguard that received next to no transformation funding was Lakeside MCP, in Northamptonshire. Chief executive Robert Harris recently tweeted: “Want change to happen? Don’t constantly put your hand out for bailouts/handouts”. He should know, he’s a former NHS England director.
- And, Mr Harris has blogged for the Reform think tank on how to transform primary care. It’s all worth a look but this apparent potshot at the vanguard reporting regime caught my eye: “Edicts from above largely blow by frontline staff who spend their time treating the sick, not poring over central demands to produce ‘logic models’.” His advice to ambitious primary care providers? “DIY”.
- Reform has published a series of articles on primary care recently. Here’s one from Don Redding of National Voices, another from Paul Corrigan, and one we ran in HSJ from Reform director Andrew Haldenby.
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.
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.