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

  • Devolution for East Anglia remains bogged down in disagreements between councils and the government. Our colleagues at LGC report that although Cambridgeshire and Peterborough want their own devo arrangement – which would reflect the local sustainability and transformation plan footprint – ministers are committed to lumping them in with Norfolk and Suffolk. Local MPs don’t like it, the councils are not agreed, but ministers won’t budge.
  • Tanni-Grey Thompson has written for HSJ on the question of prevention. While ministers’ plans for policy to prevent obesity in children have advanced “painfully slowly”, Baroness Thompson singles out for praise NHS commissioners’ efforts in pushing the agenda. Read the whole thing here.
  • Is Simon Stevens reverting to old fashioned command and control tactics, asks Thomas Cawston. He draws a contrast between the Five Year Forward View’s “third way” approach to transformation, which would be both locally led and centrally guided, with the more recent General Practice Forward View. “The new roadmap for primary care reveals less about the future direction of general practice than the journey of Simon Stevens and his NHS England. While the Five Year Forward View tried to be a different kind of beast, the General Practice Forward View is a very traditional Department of Health command paper,” Mr Cawston writes.
  • A legal battle is underway over the cost of out of hours GP services. It revolves around the practice of out of hours providers paying GPs as self employed individuals rather than putting them on the payroll. A dispute in Lincolnshire could become a test case. HMRC is checking the employment status of GPs. But any moves to switch doctors to payroll could have a major financial impact on the sector – the reform and integration of which is vital to new care models – by making employers liable for national insurance, annual leave and sick pay.

When should councils take control?

A couple of weeks ago I set out on Twitter the reasons why I thought councils should not have a role in setting hospital budgets – an idea floated at last month’s conference of adult social care directors. Beware of simple structural solutions to ill-defined problems, etc. In response, councillor Jonathan McShane of Hackney and the Local Government Assocation (who happens to represent the ward where HSJ’s offices are based), asked me: “why do you hate councils?”

My answer was that I didn’t, but I didn’t think it was generally a good idea to put them in charge of the NHS.

Two recent developments have given me reason to revisit that assertion.

First, Warwickshire clinical commissioning groups are jointly tendering for Child and Adolescent Mental Health Services (CAMHS) – but the procurement is being led by the county council.

Second, MPs have published a damning report about the standard of mental health services for children in care.

In the case of the Warwickshire tender, there are a number of reasons why this is interesting.

The local context is South Warwickshire CCG’s recent U-turn on another novel tender, for community services. Warwickshire commissioners have decided to replicate the 0-25 approach taken amid some controversy in Birmingham– the crux of the disagreement there was the impact on the existing adult services provider and the knock on effect on the sustainability of the rest of its services once it lost services for young adults. Let’s hope this Warwickshire tender doesn’t undermine other services or corrode relationships.

And, I’d like to hear more about Warwickshire’s decision to contract with a “lead provider” rather than an “integrator” because, it says, the latter is too expensive. Plenty of other places – for instance Tower Hamlets and Bedfordshire– have used integrators to bring together but not directly provide services. Does it necessarily cost more, and if so, why does anyone do it?

But the most interesting thing about this approach is how it brings together CAMHS with wider children’s public health and education services.

It is also – on the face of it – a simplification of existing arrangements. I’ve written before about the contortions commissioners appear to need to go through in order to make services more streamlined. While a single contract for two and a bit NHS commissioners plus a county council has all sorts of complexities built into it, at least the end result should be fewer commissioner-provider interfaces than there were before. The approach feels sensible – with the caveat that there is still a long way to go and plenty that could go wrong.

The second thing that has happened to make me think again about the role of councils in commissioning NHS services is the publication of a report by the Commons education committee on mental health services for “looked after” children.

These children are being failed by the system – in particular in the difficulty they are having in accessing these services. Mental health services for looked after children are disappearing in some areas, the report says, thanks to cuts in both NHS and council budgets. 

The “exam question” (in the fashionable Stevensese) for local commissioners is: how can we improve the mental health of some of our society’s most vulnerable people? The answer has to involve both the NHS and local councils, and the primary commissioner here must be local authorities: it is they who have the most responsibility for vulnerable children through their children’s social services departments, it is they who commission early years services, and they who hold the public health budgets which should be the bedrock of preventive care. A single act of commissioning to bring together all the services that can prevent and alleviate mental ill health is the sensible thing to do.

For those children, even where they suffer ill health, the council is the body charged with responsibility for their overall wellbeing, and therefore should be the primary commissioner for the services they use – including health services.

There is a clear health argument for investing in council commissioned preventive services for children: children whose health is not protected early are more likely to suffer ill health for life, and become regular and intensive users of mental health services.

Yet budgets have been raided over a period of several years. As a consequence too many looked after children are adrift in the growing limbo that is opening up between increasingly inaccessible social services and the NHS.

The divide between council and NHS spending on these vulnerable people must be closed, and investment increased.

Ministers seem to understand the need to do this between health and social care for older people (although the policy response has been hopelessly unequal to the task). Yet a less-acknowledged parallel need exists for young people too.

The better care fund was a bad policy borne out of a good idea, and having previously called for it to be scrapped, I’m not about to go on the record arguing for another one for young people.

However, if local commissioners are attempting – within the limited financial means available to them – to close this gap and improve health over the longer term, that has to be worth a shot.