Ockham Healthcare: Supporting innovation in General Practice

What the new ACO contract means for general practice

It appears NHS England have gone cold on Accountable Care Organisations with the publication of the latest guidance. But what might the new draft contract mean for general practice and what should interested GPs consider doing next? Ben Gowland works his way through the tangle of documents and suggests some of the answers.

NHS England have recently published an updated version of the MCP contract, now termed an Accountable Care Organisation or ACO contract. As ever with NHS England, there are an inordinate number of documents, all of which are inexplicably difficult to find on their website (here). I discussed the original publication of the draft MCP contract in detail previously, and would strongly recommend you take a look at this to understand the key components of the different versions of the model (the “virtual”, the “partially integrated” and the “fully integrated” MCP) and their implications for general practice. In this article I will focus on what is different or has changed in the new publication.

The most noticeable shift is the overall drop in enthusiasm the documents display for the new models. Where previously you had the sense that those producing the documents believed ACOs to represent the next step for the NHS that is now no longer the case. Instead, it has become clear that Accountable Care Systems (ACS’s) are the new black, and ACOs may instead be something of a distraction. Take this paragraph for example, ‘ACO procurements are lengthy and complex, and the development of ACOs relies on a strong underlying approach to care design, engagement and collaboration. For these reasons, most parts of the country are looking to become ACSs before they consider whether to introduce ACOs for some or all of their local population.’

An ACS, for those not familiar with the concept, ‘is an evolved version of an STP, potentially covering a sub–set of an STP’s geography, in which commissioners and providers, in partnership with Local Authorities, take explicit collective responsibility for resources and population health. In return, they will gain greater freedom and control over the operation of their local health system and how funding is deployed’. ACS’s can cover large areas relatively quickly, do not require contractual or legal changes, and represent the quickest route for the NHS out of the current purchaser provider split. ACOs must demonstrate ‘consistency with STP/ACS plans for the future’, and, just so that we are clear, ‘In most places, we expect that ACS development will precede the development of ACOs in order to lay the right foundations.’

The shift from “MCP” to “ACO” has come about whilst previously the draft contract applied only to MCPs, with a separate contract promised for the PACS models, now the contract ‘is usable for accountable care models generally, including MCP and PACS models’. A sceptic might think that given the shift of focus towards ACS’s, and the lack of traction generally for the PACS model, that centrally it was not deemed worth the effort to fulfil the initial promise of a separate PACS contract.

Nevertheless, there have been some interesting developments in the iteration from the original draft. There is confirmation that activity sub-contracted from the ACO to practices will be pensionable. The fully integrated model no longer relies on APMS directions, replaced by less prescriptive directions that offer more local freedom. GPs can sell their premises to the MCP, ‘where the MCP has the capital to buy the property and there is clear value for money’. GPs may be able to buy in as partners or owners of MCPs, but given the cost that is needed to cover (amongst other things) the downside risk of the contract I would suspect it will be beyond the reach of most individuals.

Much has been made in the GP press of the changes to GP practices’ “right to return” (from the fully integrated model back to the original GMS/PMS contract), whereby the patients will not necessarily follow the contract (you can have your contract back but not your list). What it actually says is, ‘If the GP reactivated in the first two years of the ACO Contract the default would be that patients previously on their registered list follow the GP to be re-registered with the practice. If they reactivate after these first two years the patients will remain with the MCP unless they request to follow the GP.’ In reality this means the practice has to decide whether or not it is going to stay or leave within the first two years.

Not all GP practices in the same area have to go down the same route, ‘It’s important that individual GPs have a choice and do not feel pushed into a particular contractual model because it is preferred by the majority. In many of the emerging MCP localities GPs are expressing interest in a range of contractual models in the same locality.’ I assume this is an attempt to move at the pace of the enthusiasts rather than be hampered by those resisting change, but I am not sure how well it will serve general practice going forward to end up in this type of mixed economy.

This version of the ‘GP participation in an MCP’ document is littered with examples and case studies of benefits existing areas have achieved or foresee. I suspect this is in an attempt to make what is essentially a very dry document into something more accessible to GPs. However, the lingering sense left by these is that the majority of the benefits highlighted can be delivered through practices working together, and so do not directly encourage GPs to take the radical step of joining an ACO. It would make sense if they were benefits that could only be achieved as part of an ACO, but by and large this is not the case.

At the same time there a strong reference in the documents to the emerging primary care home model, ‘All accountable models build on strong primary care foundations. In many Vanguards the model is based on local units of integrated primary care provision serving natural communities of 30–50,000 population.’ I think this is an important statement for GP practices trying to find a way through all of this. If ACO development is uncertain whilst Accountable Care Systems come to the fore, and the many of the purported benefits can be delivered by working with others, then developing a clear focus on a local population and building effective working relationships with the other local practices (in whatever form that might take) might be the most pragmatic step for practices to take right now.

Navigating the podcast: Introducing new roles

Every week here at Ockham Healthcare we publish a new episode of the General Practice podcast, in which I interview people introducing new ways of working into general practice. Now with over 18 months of episodes in the podcast library there are a whole range of different case studies and individuals to choose from. As a result, the most relevant episode may be increasingly difficult to find. We have introduced a podcast index, but we wanted to create some more useful “maps” to help you find the most relevant episode for you. This week I take a look at where to find the best information about introducing new roles into general practice.

Where do you start? A helpful place is in our recent podcast with Dr Stewart Smith (Episode 75) from St Austell Healthcare. He describes how when thinking about introducing new roles their practice started by undertaking an audit of everything the GPs were doing that could potentially be done by someone else. New roles are not a luxury item in general practice. They are necessary because GP recruitment is becoming increasingly difficult (in some places impossible!), and as the workload becomes increasingly unmanageable new roles are necessary just for practices to remain sustainable. Stewart and his team used the results of the audit to identify locally what work could be taken off the GPs, and who could undertake it.

The headline new roles in general practice are paramedics (Charmi Rogers, Episode 23) who can support GPs with managing the urgent demand as well as undertaking home visits, pharmacists (Karen Acott, Episode 15, and Ravi Sharma, Episode 5) who can undertake medication reviews and run their own clinics, and physiotherapists (Neil Langridge, Episode 17) who can help with the high volume of patients presenting with joint pain. All of these can make a real difference to GP workload, while at the same time improve the quality of care for specific groups of patients.

Also on the rise are physician associates or “PAs”. Initially met with some resistance by the profession (seen as under-qualified for the challenges of general practice) they are now increasingly being welcomed by practices, because of the more general support they can provide to GPs. We ran a podcast mini-series in which I spoke to GP Dr Joanna Munden (Episode 52) about her experience of employing PAs, to Ria Agarwal and Andy King who are PAs working in GP practices about what it is like from their perspective (Episode 40), and to the RCP’s PA lead Jeannie Watkins (Episode 43) who explained that while there may not be many PAs around at present, the pipeline means they will be much more plentiful in a few years’ time.

What Stewart Smith’s audit also found was that it is not just on the clinical side that GP time can be saved. We spoke to Jonathan Serjeant (Episode 46) about how training administrative staff to manage GPs’ post can save each GP half an hour or more a day, and to Nick Sharples (Episode 62) about how work can be triaged away from GPs by trained receptionists in what is known as “active signposting”.

One of the reasons Stewart, and Jonathan Cope at Beacon Medical Group (Episode 57), are worth listening to is because they describe how these different roles can be brought together into one practice, and harnessed to redesign the way on the day appointments are managed, visits are carried out, in fact the way the whole practice operates. I also provide an overview of some of the wider lessons I have gleaned from talking to the experts about the introduction of new roles (Episode 32).

I hope this serves as a useful map to the podcast for those of you seeking more information about the introduction of new roles. If there is any individual role, or aspect of the introduction of new roles that we have missed, or that you think we could cover in more detail, do let me know (ben@ockham.healthcare) and we will try and include it as a future episode!

Kaizen vs Kaikaku: Does general practice need big bang or incremental change?

Before I moved into the world of general practice, I used to live in the world of service improvement. It was a strange world, with its own language, traditions and practices. I kind of liked it, and look back on it fondly sometimes as you would when you remember a great place you once visited, like that trip to Sydney in 2003 when England won the rugby world cup, where they put beetroot on their burgers and thought calling me “blue” was hilarious on account of my red hair.

Anyway, in the service improvement world there is an ongoing debate about which type of change is best: should you go for small-scale continuous improvements, or a big bang change? In the world of general practice we are now facing the same question: can we adapt the existing model of general practice through incremental improvements into something different, or is a more radical approach required? Evolution versus revolution.

In the improvement world they use the terms “kaizen” (for evolutionary incremental improvement) and “kaikaku” (for revolutionary radical improvement). In the GPFV, high impact action number 10 is; “Develop quality improvement expertise”. Some believe this is the most important of all the actions because it gives practices a mechanism for making the other changes successfully. It includes techniques such as “plan, do, study act cycles” (or “PDSA cycles”) which encourage rapid cycles of testing of changes to enable successful adoption. This, and the techniques like it, are based firmly in the kaizen school of incremental improvement.

I have recently questioned whether the GPFV is failing to have the desired impact because it is trying to tackle each of the problems individually, rather than creating a clear vision for the future. A number of responses have challenged this, suggesting in particular that if all of the 10 high impact actions were implemented in a single practice that in itself would constitute our required vision.

But would it? If every practice implemented each of the 10 high impact actions, in a structured, incremental way, would the current problems of general practice be over? Certainly life would be better, but would it be enough?

Where they got to in the improvement world is that it is not an either/or. Big bang change is needed to break paradigms and elevate the awareness of people to a higher level of understanding. It is needed in addition to continuous improvement, not instead of it. While some problems can be solved by incremental improvement, others do require radical improvement to start with.

The challenge facing general practice is such that I don’t believe incremental improvement on its own will be sufficient. It needs kaikaku as well as kaizen. While the 10 high impact actions are an important part of the transformation needed in general practice, they are not the totality of it. I understand the GPFV is more than the 10 high impact actions, but if they are the element that provide the vision of the future, my contention remains they are not enough and a more radical transformation is needed.

Is the Primary Care Home the “answer” for general practice?

Recently I have been wondering if we have been going about tackling the challenges in general practice all wrong.

We have been focussing on the problems practices are experiencing now, and trying to systematically tackle them one by one. Logical. But it assumes the cuts are only superficial, and once they are patched up individually general practice will be well.

The General Practice Forward View (GPFV) approach is to identify each of the issues general practice is facing, and to come up with “answers” for all of them. So for example workforce is the issue and 5000 more GPs is the answer. Or infrastructure is the issue and the ETTF (estates and technology transformation fund) is the answer. Or workload is the issue and contract changes to stop secondary care increasing general practice workload is the answer.

You could argue the real issue is underfunding, and that more money is the answer. But despite the rhetoric, there never was an extra £2.4bn for general practice (see here for more detail). In 2016/17 not only was funding flat (taking into account inflation), growth was half that received by acute trusts. We operate in the system we operate in.

But whether or not the “answers” are working individually, they certainly are not working collectively. I don’t think it is a failure of implementation. Rather, the approach was wrong in the first place. Wrong because it started with the problems, not the strengths of general practice. It started with individual challenges, rather than a compelling vision of the future. And it started with the premise of offering more within a system that cannot offer any more.

Compare this with the NAPC’s primary care home initiative. I knew quite a lot about it, but what I couldn’t quite comprehend was how it helps general practice meet its current challenges. I spoke recently to Dr Nav Chana, Chair of NAPC, and asked him about this. What I learnt from that conversation was the starting point of the primary care home is not so much the sustainability of the current organisational infrastructure of general practice, but a desire to improve the health of local populations, to bring increasingly fragmented workforces together, and to put the control of resources for that population into one place.

What that then means for GP practices as organisations they don’t know yet. What they do know is they are building on the strengths general practice currently has, they are making the service attractive to those who work there again, and that by focussing on meeting the needs of the local population the most appropriate future form of general practice will emerge.

It makes sense. A model that meets the needs of a defined local population will solve recruitment problems because it will attract staff to work there, will solve financial challenges because it will attract investment and funding, and will solve workload issues by different staff groups all working effectively as an integrated team.

Of course it will need help to get there. But by using a future focussed and population centred approach, the primary care home initiative has much more chance of providing general practice with a realistic route out of its current malaise than the backward looking, issue based approach of the GPFV.


What GPs should consider if they are thinking about partnership

If you are a GP who is thinking about becoming a partner, what questions should you ask to be sure you are making the right decision? In this guest blog (his third for Ockham) mergers expert Robert McCartney introduces a checklist of things you should consider to help you make the right choice. You can download and print off the checklist following the link beneath the blog.

We undertake a lot of work assisting practices in developing plans for the future and redesigning systems which strengthen general practice. However, much of this work is undermined by the simple fact that there are insufficient numbers of GPs willing to be partners.

Exploring this with a range of junior, salaried and locum GPs it has become evident that the biggest issue is a lack of understanding about the potential benefits and opportunities partnership still offers.

Work must continue to tackle the issues facing general practice but, at the same time, we need to highlight the positive side and help develop the vision of what general practice could look like if the independent contractor status is secured for future generations.

Feedback highlights that potential GP partners do not know what questions to ask to make an informed choice about the opportunities within practices. The checklist, which we have made available below, has been produced to help those GPs considering partnership for the first time. It is not a complete list but should help structure your thoughts around the type of information you need to know before agreeing to invest in the practice.

As a general point it is recommended that you obtain support and advice throughout the process. The local LMC and trusted GP partners will be able to assist you in identifying when an opportunity is suitable for you.

Entering partnership includes accepting a degree of responsibility for the management and running of the business and you should therefore invest in gaining some simple business skills. It is not necessary to enter onto a MBA course but finding suitable sessions on understanding accounts, HR responsibilities and the principles of leadership will all help you once you enter partnership.

When you are considering the list remember that the final decision will also come down to whether you feel the ‘fit is right’. The culture, relationships and general environment of the practice must suit you or have the ability to develop with you over time. The empirical data collated will give you confidence that you understand the practice but only through spending time and talking with all members of the practice will you be able to make an informed decision.

Download the checklist here.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the third in a short series of blogs he has written for Ockham Healthcare. If your practice needs a helping hand with its fledgling relationships, you can contact Robert via e-mail at rm@mccartneyhealth.co.uk or call 0203 287 9336.

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