New models of NHS Care
Following publication of the NHS five year forward view, commissioners began to develop new, population-based models for local health services. The NHS long-term plan published in January 2019 reiterated the key role for new models of care for the long-term development of the NHS. The plan focused on integrated care systems, which are to be in place across England by 2021.
The new models of care are based on the idea that services work better if they are integrated. They also seek to develop ways to treat more patients in settings outside of hospital.
NHS England ran a consultation on integrated care, which ran from August 2018 to the end of October 2018.
The new ways of organising care are were a key aspect of the STPs which were full of discussion of the formation of multispeciality community providers (MCPs), primary and acute care systems (PACS), local care organisations (LCOs) and integrated/accountable care organisations (ICOs/ACOs). These terms were scattered throughout the STP documents, but meant slightly different things in each area.
The aim in the NHS long-term plan is full coverage of England with integrated care systems (ICS). The NHS has only two years, to 2021, to set up these ICS. The plan notes that they will develop out of the current STP areas, and it is therefore likely that in many areas the ICS will develop out of ongoing experiments with integrated care that began several years ago under the term Vanguards.
This page aims to explain some of the new models of care.
Integrated Care Systems (ICS) and Integrated Care Organisations (ICO)
Following the publication of the NHS long-term plan in January 2019, it is clear that integrated care system (ICS) is the preferred model of care for NHS England. The plan notes that ICSs will be developed across all of England by 2021.
The ICSs will evolve from the current STPs, resulting in around 42 ICS each of which will cover a population of approximately 1 million, according to the HSJ. All STPs discussed the formation of an integrated care system (ICS) or an integrated care organisation (ICO).
ICS, as proposed by NHS England, aim to involve local authorities, NHS trusts, GPs, the voluntary sector and the private sector. The NHS long-term plan states that
"An ICS brings together local organisations to redesign care and improve population health, creating shared leadership and action. They are a pragmatic and practical way of delivering the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care, consistent with what doctors report is needed"
The aim is to have a single commissioning organisation within a CCG:
"Every ICS will need streamlined commissioning arrangements to enable a single set of commissioning decisions at system level. This will typically involve a single CCG for each ICS area."
Service integration can be delivered locally either:
- through collaborative arrangements between different providers, including local ‘alliance’ contracts; or
- with one lead provider being responsible for the integration of services for a population. In this case the Integrated Care Provider (ICP) will use a new ICP contract. This contract will allow the integration of primary medical services with other services.
According to NHS England, every ICS will have:
- a partnership board, drawn from and representing commissioners, trusts, primary care networks, and possibly local authorities, the voluntary and community sector and other partners;
- a non-executive chair (locally appointed, but subject to approval by NHS England and NHS Improvement) and arrangements for involving non-executive members of boards/ governing bodies;
- sufficient clinical and management capacity drawn from across their constituent organisations to enable them to implement agreed system-wide changes;
- full engagement with primary care, including through a named accountable Clinical Director of each primary care network.
It is likely that if the ICS develops to have integrated care providers, then whole population budgets (WBP) will be set. This is a budget for the whole of the population served by the ICP, across the services covered by the contract. This approach has been developed to encourage the promotion of whole population management, prevention, self-care and a focus on outcomes.
Advocates of integrated care organisations claim that if the organisation has a limited budget for a population, this acts as an incentive for the organisation to keep people as healthy as possible to decrease overall use of healthcare services, and to minimise the use of high-cost hospital-based care by ensuring effective community-based provision.
More details on ICO and ICS can be found at our Integrated Care Organisation page here.
The Dudley Contract
The area covered by Dudley CCG is the most advanced in its development as an integrated care system and was due to create an integrated care provider and award a contract in 2018. It has been a number of years in the making. The area was one of the 14 areas tasked by NHS England in 2015 to develop a multispeciality community provider (MCP) model of care focused on community care and moving care from hospital-based services out into the community. The areas were known as vanguards (see below).
In June 2017, Dudley CCG became the first MCP vanguard to advertise a contract for its MCP. The contract notice issued by Dudley CCG and Dudley Council stated that the 15 year contract worth £3.4 to £5.4 billion will cover all community-based physical health services; some existing out-patient services; primary medical services; urgent care and primary care out of hours services; adult social care services; mental health services; end of life care; plus IT and management activities currently carried out by the CCG. The contract will cover around 300,000 people. The contract involves a capitated budget.
The contract could extend to cover more areas, including older people's care (including care homes, home care, dementia gateways and reablement services) and learning disability services (including care homes, supported living, other community based provision); mental health services (care Homes / supported living / recovery model provision); plus many other services currently commissioned from the voluntary sector and services commissioned to support the public health and/or social care commissioning operations of Dudley Metropolitan Borough Council and Dudley CCG.
The closing date for tenders was 13 July 2017 and the contract was due to begin 1 April 2018. In August 2017, Dudley CCG announced that its preferred provider to operate the contract was a consortium of local GPs, The Dudley Group Foundation Trust, Birmingham Community Trust FT; Dudley and Walsall Mental Health Partnership Trust and the Black Country Partnership FT.
There have been a number of issues surrounding the contract and the organisational changes needed in the area. The original option to create a consortium met with VAT issues. In January 2018, Dudley CCG reported that the implementation of the contract has been delayed and the contract will not be awarded until late October/early November 2018 with a start date of April 2019. In 2018, Dudley CCG announced that it is to split its main acute trust, the Dudley Group Foundation Trust, in two, leaving a residual acute trust and creating a new multispecialty community provider (also now known as an integrated care provider). The latter would hold the integrated MCP contract now known as an integrated care provider contract. In January 2019, however, Dudley CCG announced that such was the complexity of the contractual arrangements, that no contract will be awarded before 2020.
The Manchester Contract
In April 2017 Manchester Health and Care Commissioning advertised a contract worth £5.9 billion for a provider of all out of hospital services. The contract, the largest ever to be advertised by the NHS, is for a ten year period. The contract is seeking what it terms a "local care organisation" to cover all community, primary, preventative, and social care services. The contract does not include hospital care. The contract is seeking a single provider, but the provider will be allowed to subcontract. This contract is being likened to an ACO.
The development has met with problems. The idea was to form a new organisation that could be jointly owned by the NHS trusts, council and GP federation, but this is not possible due to existing laws. There are also issues of VAT liabilities and exemptions, as these are applied differently between NHS trusts and private entities when it comes to subcontracting services from suppliers and could result in additional charges.
In January 2018, the HSJ was told that there were concerns about the timeline for launch of the LCO, "with senior figures describing it as “unrealistic”."
The HSJ was told by an MHCC spokeswoman that the “local care organisation” will still go live from April, but the services will be provided through “existing contracts and partnership agreements”.
Multispeciality Community Provider (MCP)
The term MCP was coined a few years ago, however areas that are developing MCPs are now just as likely to call them integrated care systems (see Dudley Integrated Care System).
An MCP is a type of integrated provider focused on community care and moving care from hospital-based services out into the community; MCPs often include primary care.
An MCP can incorporate some services generally based in hospitals, such as some outpatient clinics or care for frail older people as well as some diagnostics and day surgery. An MCP often includes mental as well as physical health services and could extend to social care provision. Under an MCP, hospital-based services not within the MCP are provided by a separate contract with a local hospital.
MCPs are generally made up of ‘care hubs’ of integrated teams, with each typically serving a community of around 30-50,000 people.
Importantly, an MCP serves the whole population, which is the registered lists of the participating practices, plus the specified unregistered population.
A fully integrated MCP, which includes all primary care, can hold a single, whole population budget for all the services it provides, including primary medical services.
In 2015, 14 MCP vanguards were set up by NHS England, these were areas which were supposed to lead the way in developing this new model of care. They serve a minimum population of around 100,000 each. These were, as follows:
- Calderdale Health and Social Care Economy
- Wellbeing Erewash
- Fylde Coast Local Health Economy
- The Connected Care Partnership (Sandwell and West Birmingham)
- West Wakefield Health and Wellbeing Ltd
- All together better Sunderland
- Dudley Multispecialty Community Provider
- Encompass (Whitstable, Faversham, Canterbury, Ash and Sandwich)
- Stockport Together
- Tower Hamlets Together
- Better Local Care (Hampshire)
- West Cheshire Way
- Lakeside Healthcare (Northamptonshire)
- Principia Partners in Health (Southern Nottinghamshire)
Integrated primary and acute care systems
- Wirral Partners
- Mid Nottinghamshire Better Together
- South Somerset Symphony Programme
- Northumberland Accountable Care Organisation
- Salford Together
- Better Care Together (Morecambe Bay Health Community)
- North East Hampshire and Farnham
- Harrogate and Rural District Clinical Commissioning Group
- My Life a Full Life (Isle of Wight)
This model of care can be developed into an accountable care organisation (ACO).
According to NHS England, there are three contract possibilities for these new models of care:
- A ‘virtual’ contract, under which individual providers and commissioning contracts are bound together by an ‘alliance’ agreement.
- A ‘partially integrated’ contract, which excludes primary medical services, but which is supported by contractual arrangements between the MCP and the GPs to lead to integration.
- A ‘fully integrated’ contract model with a single whole-population budget across all primary medical and community based services (and potentially acute services). Because primary care services would be commissioned under the new contract, the fully–integrated model requires GPs to be released from their current contracts.
In August 2017 NHS England published a new contract and guidelines that will cover the delivery of all accountable models of care, including the delivery of primary care and other services through a single contractual model; this contract can also be used for MCP and PACS models of care. The model still contains three possible forms of contract approach - virtual, partially-integrated and fully integrated.
The contract and guidelines published in August 2017 are subject to revision.
Contract duration will be much longer than is usual for an NHS standard contract at 10 or 15 years.
Payment to the MCP/ACO will be made up of three parts: a whole population budget for the range of services covered; a new performance element; and a gain/risk share for acute activity.
According to NHS England, the contracts for the new models of care can be held by a community interest company, a limited liability company or a partnership, or by a statutory NHS provider.
The development of ACOs is the subject of much controversy and legal challenges. See our page on Accountable Care Organisations for more details.