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

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The week in new care models

  • We’re expecting a load more detail later this month on the new contract for multispecialty community providers. Ahead of that my colleague Dave West has found out the six areas that will be working intensively over the next year to adopt the contract - also known as a new voluntary GP contract. Two have “super practices” at their heart, but others are looser groups of practices.
  • The vanguards are already improving people’s lives, writes new care models director Sam Jones. Her comment piece for HSJ highlights the enhanced health in care homes part of the vanguard. With all the usual caveats about the difficulty in measuring success, she does point to some impressive results emerging from some sites, in the form of lower hospital admissions from care homes, shorter lengths of stay when they are admitted, and reduced medication costs.
  • Andy Burnham is thinking about running for mayor in Greater Manchester. This is interesting for a number of reasons. The former Labour health secretary, and more recently shadow health secretary, has previously been critical of the project, having raised suspicions about whether it was funded adequately, and whether local arrangements might undermine the national aspect of the NHS. Assuming his misgivings have been assuaged, he would be an interesting candidate, because his final stretch on the health beat focused on “whole person care”, a serious proposal to systematically join health and social care services. The devo arrangements in Greater Manchester represent his best opportunity to put it into practice any time soon.
  • Former Tony Blair adviser and general health policy influencer Paul Corrigan (and therefore connection of Simon Stevens) says the Five Year Forward View’s vision of transformation to create a sustainable system is not being followed through. In a blog for the Nuffield Trust, he says national leaders are stabilising the system now, and postponing transformation until later. However, this approach “doesn’t fit with NHS England’s analysis of the depth of the problems.” He writes: “The Forward View would argue that pumping this year’s transformation money into the 2015-16 deficits will do nothing to solve the bigger deficit in 2017-18 and onwards.” Do new care models provide better, more cost effective care than the existing system? “If they do, they carry out the task that is needed. If they don’t, then we are left trying to stabilise a system that cannot be stabilised.” For more on this, see the section below on the “integration paradox”.

The integration paradox

Before Simon Stevens’ vanguards, there were Norman Lamb’s integration pioneers.

When Mr Lamb signalled that integration would be one of his absolute top priorities as a minister, he was greeted with a wave of enthusiasm across the NHS. Some of that was probably born out of surprise that, after the Lansley reforms, ministers were in fact capable of listening to the service and focusing on improving care.

The programme aimed to identify the places which had already made significant progress on integration, and give them the support – and perhaps more importantly the permission – to go further, faster, and lead the way for everyone else.

The Department of Health’s evaluation of the programme has found that the pioneers didn’t make much progress in their first 18 months. Ordinarily that would be unsurprising: service redesign is hard, and risky, relationships don’t cement themselves overnight, and the barriers are real. But the pioneers were supposed to be about scale and pace, so on their own terms the lack of progress must be viewed as a disappointment.

Mr Lamb is certainly disappointed, and has gone on the record in my piece on the evaluation to detail his frustrations with what he felt was a lack of support for the programme from NHS England. Mr Lamb’s exasperation over the limits of his ministerial powers has been something of a theme for him.

No-one should be surprised that, where little extra funding or central resource is available, intractable obstacles such as payment systems and information governance rules are not overcome.

In contrast to the pioneers, vanguards have had more investment, and have a big national team working on those barriers – albeit more slowly than may have been expected at the outset.

So does the pioneer programme hold any lessons for the vanguards?

There’s one big one: the “integration paradox”, as identified in the evaluation. The authors point out that the very things that make integration necessary (financial and operational pressures), are the same things which prevent it being implemented. Those pressures increase the incentives “to defend existing roles and resources for fear of something worse”. The study also found that as providers came under pressure to hit performance targets, integration became a less urgent priority for them.

All of this applies to vanguards as much as pioneers, and explains why some vanguards have (unsuccessfully) asked to be given a bit of leeway from regulators on finance and performance in the short term.

The effect of this has been to make integration, in Mr Lamb’s phrase, a “second order priority”, while a desperate scramble to regain control of the finances takes precedence in the minds of many national and local leaders.

The drive to improve finances is inevitable and necessary. However, the choices national leaders have made about how to go about it has also undercut the integration agenda in another important way: in recent months the line dividing purchasers and providers has sharpened. We have seen orders to increase the use of contractual penalties, and directives to use payment by activity rather than block contracts. Providers and commissioners have been rowing about CQUIN. Control totals have emphasised organisational, rather than system, solvency. In all, the 2016-17 contracting round has been extraordinarily tough, and in some cases acrimonious.

The problem with all this is that it has entrenched oppositional, transactional behaviours between commissioners and providers, when integration and transformation need strong relationships based on trust, and a mutual ownership of all financial problems.

We know that you can’t contract or restructure your way to integration, and that relationships have to be got right first. The NHS’s recent response to the financial challenge has run counter to that.