Part three: Contracting and corporate structures
Integrating health and social care is like assembling a giant set of three dimensional jigsaws across the country…
Published 15 June 2016
We asked five leaders from across the health and social care landscape to give us their views on the best way to deliver the NHS Five Year Forward View.
Chief Executive of NHS Providers
The NHS Five Year Forward View (5YFV) maps out at least a 10-year journey of radical reform, says Chris Hopson, Chief Executive of NHS Providers. Hopson says there is now a much clearer vision of where the health and social care community ought to be going, although there is no one dominant road to the goal.
He is not fazed by comments that the pace of change is too slow. “There was a danger that the 5YFV implied that all this could be delivered within three to five years. This is a five-to-ten year journey, if you look at how integration has happened in other national health systems,” he says.
That is because getting local health and social care systems aligned takes much longer than people expect and those integrated systems can’t work without a range of enablers such as integrated care records, multi-disciplinary teams and aligned governance and payment systems.
While an alliance contract or a capitated health budget “can be grabbed off the shelf” once they’ve been created in one area, Hopson says that what can’t be bought is the time it takes to bring local health and social care leaders together, “agreeing that they want to work together, agreeing what form the integration will take, and agreeing what the process will be”.
He argues that there are a range of different ways of creating integrated health and care systems and each has its pros and cons. For example, Hopson feels that some of the multispecialty community providers (MCPs) have already forged very strong links with their Clinical Commissioning Groups (CCGs), primary care, and some social care, yet they are perhaps weaker in fully incorporating the acute sector.
In parts of the country which are seen to be more advanced in terms of integration, Hopson says that ground-breaking work started up to seven years ago. “Most of those advanced systems will tell you that it is about 18 months to just get everyone around the table and get real clarity and alignment about what we are going to do.” He says the immediate national goal is drawing up Sustainability and Transformation Plans (STPs), which need to chart, for each local community, how they will reach new care models.
Former Chief Executive of NHS Confederation
Mike Farrar feels there is good progress on the NHS Five Year Forward View (5YFV) being made on the ground but it has simply not been widely publicised and there are emerging barriers to progress.
He is concerned by the slow pace of integration with primary care. “Primary care is reorganising itself to operate at scale but it is not connected sufficiently to community and acute services, especially worrying as this is where the NHS is going to get most added value.”
The mechanisms to enable these connections are there in the shape of federations, super practices, and via MCP and Primary and Acute Care Systems (PACS), but Farrar says the ultimate driver will be economic. “GPs may find that they will be better off stepping into new local contracts.”
Commissioning, contracting, and procurement arrangements also need revision to speed the pace of change. “NHS England should push ahead with moving from co-commissioning to giving integrated budgets to commissioners.”
Farrar believes it is unlikely that the NHS will face the situation where an Accountable Care System (ACS) run by a trust could face challenges under competition law.
“I think [competitors] will be asking, ‘how do we respond to this constructively. Instead of being competitors we can operate securely as sub-contractors’. They will be understandably reluctant to challenge the decisions of their major buyer.”
He would encourage the NHS to harvest the strategic expertise of international health providers, pharmaceutical, science and technology companies. “There are already some interesting conversations taking place along these lines. Celesio, which owns Lloyds Pharmacy, have partnered the Lakeside Healthcare MCP. Salford has talked to big technology suppliers Allscripts – the giant US practice management and health technology company – about how data can help them reduce vacations in practice.
“Elsewhere, the Christie Hospital is talking with pharmaceutical companies about cancer budgets for the whole of Manchester.” These are all examples of innovative new partnerships that are emerging.
Head of Policy and Delivery at NHS Clinical COmmissioners, the membership organisation for Clinical Commissioning Groups
While Clinical Commissioning Groups (CCGs) remain fully committed to the aims of the NHS Five Year Forward View (5YFV) and the focus on integrated care, Julie Das-Thompson is concerned that “there is a real risk of heading off course”.
She says the impact of local authority cuts “play through to the NHS and create more pressure on the health services”. Das-Thompson says CCGs can only work with the allocation they have been given, “however, it is clear that the money doesn’t stack up across the whole health and care system.”
She stresses that additional income must be “explicitly married to quality outcomes and commitments to move quickly to new models of care”.
She wants “the full commitment” from the Government and NHS England to an approach that allows all parts of the NHS to work together to find the local solutions to the challenges of 5YFV. She feels clinical commissioners and partners, such as council Health and Wellbeing Boards, are best placed to understand the needs of their local populations.
“CCGs are more than capable of taking this agenda forward but in so doing they must be allowed to concentrate on the bigger picture. This is about moving beyond immediate priorities to invest in the long-term needs of our populations.”
Ensuring CCGs have the freedoms and flexibilities to “focus on the long-term view” is one of five key aims NHS Clinical Commissioners (NHSCC) has identified that will release the potential of CCGs, and is published in the recent document Local solutions to national challenges.
The other four aims are to:
Chief Executive, NHS Partners Network
David Hare says the NHS can gain huge benefits from working with the independent sector in many areas including enhancing clinical care in patients’ homes and bringing diagnostics into the community.
“Hospital community services and clinical home healthcare are really emerging areas of innovation and investment; we bring new ways of doing things that will reduce costs.
"This is an area where a huge amount can be done to help the NHS become sustainable and efficient. Much higher acuity services are being delivered in patients’ homes resulting in quicker and earlier discharge from hospital. We are forming different workforce solutions and reducing the pressure on the acute setting. There are some really good examples of virtual awards and wider clinical home healthcare solutions that are the future.”
NHS private sector partnership work can draw on the capital commitment in the 2015 Spending Review to redevelop services such as imaging and endoscopy closer to patients’ homes. “For a long time the NHS has struggled to understand how to invest in prevention and new and remodelled services outside hospitals, which would reduce the burden on NHS acute sector. The NHS just needs to allow its organisations to take more risks because new models will emerge.
Commissioning, contracting and procurement need to be streamlined and co-ordinated so there is an “alignment of objectives” in the face of what he calls a “very fragmented NHS architecture since the Health and Social Care Act”.
“The real shift outlined in the NHS Five Year Forward View (5YFV) and the NHS Mandate is towards saying ‘it is for patients’ and providers must respond to that and generate services that are in the patients’ best interests rather than simply what works best for the providers.”
Hare does not feel the need for any legislatory changes to override concerns around the provider/commissioner rules in the 2012 Act. “If you look at diagnostic imaging for example, in many cases it is often that trusts have commissioned from the independent sector rather than Clinical Commissioning Groups (CCGs).
There will always be a buyer and there will always be a seller no matter how you structure the NHS.”
Senior Associate, Kings Fund
To speed up the development of locally integrated services, Ben Collins calls for the establishment of dedicated project teams backed by sufficient investment.
“My sense is that some areas are trying to do major transformation on a shoestring,” he says.
Major change may take as long as a decade, and to future-proof integration work against the vicissitudes of politics Collins urges “local leaders to commit themselves to the longevity of these programmes”.
“Vanguard funding may dry up after a couple of years and other initiatives might come along. The stability will come from local leaders who are committed to a direction of travel, and who are willing to work ferociously towards it in spite of the veracities of national policy.”
His other worry is the “massive tension between the short-term need to balance budgets very quickly and the longer term transformation goal."
“The pressure and degree of national scrutiny on hospital chief executives is immense and that makes it hard to lift your head up and think about transformation in the medium term, even though we know that is the solution to the NHS’s problems.”
Collins highlights that advanced areas such as Salford or Northumbria don’t appear to be having any problems as a consequence of providers taking on some roles previously delivered by commissioners.
“In Salford the commissioner is playing a much more strategic role in setting objectives for an integrated system, and Salford Royal is playing the role of integrator taking over the role of many services.
“In future it will be delivering acute hospital services, community services, adult social care and bringing a lot of services together in one organisation.