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New care models: Emerging innovations in governance and organisational form

The NHS five year forward view, published in October 2014, proposed two models for bringing together health services in local areas (NHS England et al 2014). Under the first model, the multispecialty community provider (MCP), groups of GP practices would come together to offer a broader range of services, including community and outpatient services. Over time, they might take responsibility for the health budget for their whole population. Under the second model, the primary and acute care system (PACS), a single entity would take responsibility for delivering the full range of primary, community, mental health and hospital services, to
improve co-ordination and move care out of hospital.

In spring 2015, the national NHS bodies announced that they would provide support for commissioners and providers to develop these new care models. Fourteen local areas would receive support to develop MCPs and nine to develop PACS. The role of the national bodies would be to provide funding for the management of these projects, advise on technical issues and help overcome regulatory barriers. The ambition is for the 23 sites to develop models that can be rolled out at a faster pace across the NHS.

The two new care models seek to integrate services much more closely in a statutory framework designed in part to promote competition between organisations rather than collaboration within integrated systems of care. They are also being developed within a set of organisational arrangements that are more complex and fragmented than any in the history of the NHS, involving multiple commissioners and providers whose contracting relationships are regulated by the provisions of the Health and Social Care Act 2012. We have argued previously (Ham and Murray 2015) that legislative and policy changes are likely to be needed to remove barriers to the implementation of new care models – an argument reinforced by the evidence presented in this paper.

During the first 18 months of the support programme, most of the MCP and PACS vanguards have focused on building effective partnerships between organisations,
developing their vision for how services need to change and testing new ways of using resources and delivering care. They are also working on the governance and
organisational changes needed to support the new systems. Providers are starting to put in place more formal governance systems and partnerships so that they can work together more effectively – in some cases aiming to create integrated care organisations or accountable care organisations.

Commissioners are considering how to contract for these new models of care and, in many cases, how to work with other commissioners in so doing. They are also reflecting on their role in the development of these new care models, including which activities they should continue to carry out and which might be better
delivered by providers. As part of this, they are developing ways to measure the effectiveness of the new systems and incentives to encourage high performance; they are also considering using innovative and longer-term contracts.

Research and evaluation consistently emphasises the importance of organisational and system architecture in supporting high performance in health care and other sectors (Baker et al 2008). How the vanguards deal with these issues may turn out to be just as important as their current thinking on new care models – for example, in allowing groups of organisations to work together as effective learning systems. This report takes stock of commissioners’ and providers’ emerging approaches to the contracting, governance and other organisational infrastructure of the PACS and MCP vanguards. It builds on the analysis and frameworks presented in an earlier report from The King’s Fund, Commissioning and contracting for integrated care (Addicott 2014).

The report draws on published information and interviews with leaders of 12 of the vanguards. It focuses in particular on a small number including: Dudley, Sandwell
and West Birmingham (Modality Partnership), Salford, Northumberland, and South Somerset (Symphony Project). The report gives a brief overview of the emerging models and a summary of the key themes arising from the interviews. The appendix provides short case studies on the five vanguards listed.

At this stage, it is only possible to provide an overview of commissioners’ and providers’ thinking on the architecture of their new systems. These arrangements
are likely to evolve considerably in the medium term as organisations gain more experience of working together. It will take longer still to build a clear picture of how effective different arrangements are in supporting strong, integrated local health systems. This paper should therefore be read as the first chapter in the still unfolding story of developing new care models – a story that will need to be updated and elaborated in the light of ongoing experience.