NHS England’s proposals for new care models to provide integrated care for a local population are at odds with the existing system for commissioning and providing services brought in by the HSC Act (2012). Building on the split between purchaser and provider brought in during the 1990s, the Act made new clinical commissioning groups (CCGs) responsible for commissioning most community and hospital-based care for their local population, and made it compulsory in all but a minority of cases for them to purchase services through competitive tendering.
But it now seems that the ‘new models of care’ promoted by the Five Year Forward View (FYFV) may take on many of the functions of CCGs. After winning the bid to provide such a model, a ‘prime provider‘ (quite possibly a private company) will develop a package of care and then sub-contract out much of the actual service provision. With ‘integrated care’ and ‘new care models’, it may be that the functions of purchasing and providing are being merged, and the requirement of the HSC Act to open up the NHS ‘market’ to competition may be selectively ignored.
As a report from the Nuffield Trust points out, new care models open the way for the involvement of large commercial prime providers because, compared with the NHS, they can afford to take on the considerable financial risks involved. But now competition may be something of a millstone for such providers. It’s noticeable that the government speaks less these days about ‘competition’ and more about ‘collaboration’. It will be interesting to see whether Section 75 of the HSC Act (the part that makes competitive tendering compulsory) will now be amended.
Much of the FYFV appears to be influenced by the work of the US-based consultancy firm McKinsey, commissioned by the Labour government to advise on making the NHS more efficient, and later, heavily involved in Conservative preparations for the Health and Social Care Act (2012). The firm’s report Achieving World Class Productivity in the NHS 2009/10-2013/14 suggested that measures that appear in the FYFV, like shifting services out of hospitals and reducing demand for health care by promoting ‘self care’ (as well as rationing health care, dropping some services and cutting 10% of the workforce, not explicitly mentioned in the FYFV), could save up to £4 billion a year.
However, McKinsey’s suggestions are little more than a series of assertions – they are rarely backed by evidence – nor have they been properly studied to show any potential costs and disadvantages. Even one of McKinsey’s directors has been heard to say “there isn’t much [that’s] evidence based about models of community care” (the same models that McKinsey wants the NHS to adopt). What goes without saying is that the suggestions by McKinsey and others for radically changing the NHS provide plenty of work for management consultants.