Blog: New Models of Care: The vanguard sites
10 March 2015
Hard on the heels of the announcement of the devolution of NHS powers in Greater Manchester (the so-called ‘Devo Manc’ model) in order to better integrate health and social care comes news of the ‘first wave’ of 29 ‘vanguard’ sites for the New Care Models Programme heralded last October by Simon Stevens’ Five Year Forward View for the NHS. There are three types of model, and two new acronyms to add to the care and health lexicon: MCPs (Multispecialty Community Providers) concerned with moving specialist care out of hospitals and into the community; PACs (Primary and Acute Care system) with single organisations providing hospital, GP and community services; and Enhanced Health in Care Homes, with no apparent acronym as yet, but – for now – let’s call it HICH, offering better joined up care, health and rehabilitation services.
As Stevens noted in his forward view, there is considerable consensus about what needs to change to improve care and health, and the shorthand for this – whether in the Devo Manc model or in other innovation – revolves around some form of integration:
“The traditional divide between primary care, community services and hospitals – largely unaltered since the birth of the NHS – is increasingly a barrier to the personalised and coordinated health services patients need. And just as GPs and hospitals tend to be rigidly demarcated, so too are social care and mental health services even though people increasingly need all three.”
Few would argue with this analysis, but while the debate around integration is of long-standing, the focus on new care models actually moves things up a gear. Successive governments over at least the last 3 or 4 decades have lamented the structural divisions (often described as the ‘Berlin Wall’) between care and health, and the mantra of ‘only connect’ has been a recurrent feature of the debate. What then – if anything - is different this time around?
Sceptics might argue that this is just rebadging or relaunching of familiar ideas. But arguably it is more than that – or at least has the potential to be so. Typically the argument around integration has been couched in an over-simplistic narrative that suggests either that structure is of fundamental importance and bringing together health and care organisations is the answer, or that cultural and leadership factors are the vital variables. Recurrent attempts since the 1970s to restructure the machinery of joint working; to create new incentives (and sometimes penalties) for collaboration, and to enable enhanced flexibilities for those eager to innovate, all testify to the continued challenge of fragmentation and the limited success in overcoming it. The conclusions from most research point to the importance of both structural and process factors, but also underline the conclusion that too often collaboration and partnership have becomes ends in themselves, rather than ends to wider means. The Audit Commission, for example, remarked in 2009:
“It is difficult to identify the extent to which pooled funds and other joint financing arrangements have directly achieved better value for money or have made a tangible difference for service users (...) The national and local focus has tended to be on process rather than outcome.”
The latest attempt to achieve better integration and to explore options through the New Care models arguably starts from a different standpoint. The central objective is not integration or closer working per se, but better integration and coherence around the needs of the patient. This is not just a semantic difference, but a qualitative shift in values and objectives. The test of the 29 pilot schemes will be if they are indeed able to achieve a better experience for patients and their families, and to offer more integrated, personalised care that enables people to achieve greater independence, to avoid hospital admission where possible (and timely discharge where not) and to postpone or avoid permanent residential care. Of course, making better use of resources and achieving savings will also be keenly anticipated.
Many of the pilot schemes are developing in sites that are well advanced in their quest for new models of working, and there will be challenges – as with any innovation – in moving from the enthusiasts and ‘usual suspects’ to mainstream working. Criticisms are also being made by those who see the proliferation of new ways of working as antithetical to the concept of a national health service, and who fear the widening of a postcode lottery by stealth. It will be important to monitor the impact of the models and evaluate costs and benefits comprehensively. How, for example, are we to assess and balance requirements around equity and universalism while recognising that a ‘one size fits all’ model is unlikely to be personalised or flexible, but difference and variation for its own sake is unlikely to be desirable? Whether it makes sense to consider options for health communities with ‘similar characteristics’ remains to be proven.
The timing of this development is not ideal. With a general election around the corner there will be plenty of accusations of ‘too little, too late’, and of opportunism, but Simon Stevens is to be congratulated on moving speedily in taking the agenda forward since his Five Year vision was published. The support for the programme with a £200 million Transformation Fund will be vital in identifying shared learning and solutions and in accelerating change.
There will be some major challenges – not least because the new models threaten well established ways of working and the relative autonomy of hospital consultants, and operating with delegated budgets across local populations will be testing. NHS England describes the new models as potentially offering the ‘complete redesign of whole health and care systems’. The tragedy of this latest attempt would be if it goes the way of previous efforts and gets bogged down in structural reorganisation and administrative process; the prize which could be in sight would be innovative models of support which integrate care and health around the total needs of patients and achieve the elusive seamlessness. For the moment it is too soon to judge, but the narrative has shifted and arguably moved to a more productive position that leaves behind the sterile debate about structural integration and focuses instead on the best means of achieving specific outcomes. It will be essential that a top-down centrally driven model of running the NHS which has characterised so much of past reform is not replaced by a new model that is professionally dominated by clinicians and frontline staff but which enables genuine partnership with patients, their families and wider communities.
An edited version of this blog was published in Guardian Professional Networks on 26 March 2015 http://www.theguardian.com/social-care-network/2015/mar/26/vanguard-sites-integration-health-social-care