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

The week in new care models

This week I will keep this section brief because the main feature is a bit longer.

I’m off for a couple of weeks from next week so see you again in August.

PACS governance and alliance contracting

It is now hard to see how a primary and acute care system will be able to go fully live in 2017-18. Although HSJ’s understanding is that it had been the plan for the first PACSs to be up and running by then, we are now hearing that implementation might be “staged”.

One big reason for this is that changes to the model of care are now butting up against the need for sound governance. Debates about governance will not make many health leaders leap out of bed in the morning, but if done well governance can help them sleep a little more soundly at night.

I’ve written before about how the new care models agenda is pulling at the seams of the foundation trust organisational model. I’ve also written about the strange web of joint ventures and subsidiary companies that might need to be put in place to create a PACS model that doesn’t annoy all the local GPs.

The latest set of issues is around how quickly you can design an organisation that does all the things a PACS is supposed to do, that is still subject to appropriately strong oversight and accountability given the lives and millions of taxpayer pounds at stake.

It’s important because unsexy, boring governance is the thing that enables leaders to know about what is happening on the wards, and to enact a change if something isn’t right. When it goes wrong, people are harmed and money gets wasted.

NHS Providers chief executive Chris Hopson has raised some concerns about the pace of change in the system through new care models and sustainability and transformation plans.

In a speech last week, Mr Hopson defended the amount of time and effort that has been invested trust boards, sub-committees and governors to ensure organisations can be held to account by commissioners, taxpayers and communities. If we are now moving to a focus on local systems rather than organisations, there is a risk of throwing the baby of good governance out with the brackish bathwater of sovereignty for autonomous provider trusts (I paraphrase).

One section of Mr Hopson’s speech is titled: “Worrying about governance and accountability isn’t pedantry”. It appears to be aimed at people in “the centre” (the driving forces behind the new care models drive, presumably?) who might be pushing service change at a pace that outstrips organisational evolution.

Mr Hopson also aimed his remarks at the sustainability and transformation plan process, which is stretching organisational governance. and accountability close to breaking point too. 

Some quotes from Mr Hopson: “I know that some in the centre think that raising these issues is being pedantic, legalistic or is a way of blocking change. It isn’t. Good governance and clear accountability allow risk to be managed and mitigated. They need to be developed thoughtfully at times of peace to enable us to manage effectively in times of trouble”.

Given Mr Hopson’s job, we shouldn’t be flabbergasted that he is defending the safeguards offered by a system of sort-of independent trusts and FTs. While victims of poor care will always argue – reasonably – that existing provider governance isn’t perfect, I am yet to hear of a similarly detailed set of arrangements for PACS (or multispecialty community providers, for that matter).

A PACS might well not be a neat entity, because there’s no simple, practical way of fusing acute and primary care. So a new sort of organisation will need to be established.

But what sort of organisation? Will a PACS have governors, then, or will it be accountable to the community it serves in some other way? Will there be anything beyond a slimmed-down commissioner function to make it accountable to taxpayers? Will there be rules about sub-committees, or what board positions each PACS should have? Should there be non executive directors, chairs and chief executives, and should NHS Improvement have a role in any of those appointments?

These are questions which would have to be answered this year, and leave time for actual implementation, if the first PACS is to go fully live at the beginning of 2017-18.

This is a good moment to highlight a story by my colleague Lawrence Dunhill, about the Morecambe Bay PACS vanguard. Most of it is about the legal blocks to delegating commissioner functions to provider organisations.

However there’s also this: “The paper said the restrictions of the [2012 Health] act meant a ‘single leap’ from the current set-up into [a PACS system] from April 2017 ‘is not possible, even if all the due diligence could be completed’.”

It’s hard enough to do due diligence on an organisation that doesn’t exist yet, let alone one which hasn’t even been defined, in time to award a contract worth hundreds of millions of pounds for the beginning of 2017-18. This applies to all new care models, not just Morecambe Bay.

So if the “single leap” from old care model to new care model is looking a bit far-fetched for this year, could a series of leaps be made?

If a new form of governance isn’t going to be ready in time for 2017-18, a sensible workaround might be some form of alliance contract, binding together the GPs, mental health, community, acute and even social care providers. That would lock in every part of the PACS, and could mandate innovative ways of working without losing the critical oversight mechanisms that exist in the trust sector until an alternative – that leaders, patients, communities and taxpayers can feel confident in – can be created.