Ockham Healthcare: Supporting innovation in General Practice

What does accountable care mean for general practice?

The NHS world is changing. I wrote last week about the impact of commissioning on general practice, and this week I consider what the move towards accountable care organisations and systems means for GPs and practices.

What is accountable care? The Kings Fund has helpfully described it as comprising of three core elements,

First, they involve a provider or, more usually, an alliance of providers that collaborate to meet the needs of a defined population. Second, these providers take responsibility for a budget allocated by a commissioner or alliance of commissioners to deliver a range of services to that population. And third, ACOs work under a contract that specifies the outcomes and other objectives they are required to achieve within the given budget, often extending over a number of years.”

Rune reading, particularly in the NHS, is a difficult game. But all the signs point to accountable care organisations and systems (often used interchangeably to describe very similar arrangements) as the direction of travel. STP plans, NHS leaders and politicians are all making noises to suggest it is exactly where we are heading, despite the reticence to create new legislation with the disaster of the last NHS legislation so fresh in people’s minds.

If accountable care is where we are going, what does it mean for general practice? To help answer that, there are three further questions for us to consider.

1. What role will general practice play in an accountable care system?

Here the options appear to be threefold. General practice could choose simply not to engage. Indeed, some of the early accountable care pilots report engaging GPs to be one of their key challenges. The problem here is some of the budget for general practice will transfer from local commissioners to the accountable care system. If this is dominated by the acute hospital and other large provider organisations there is an obvious risk some funding streams will dry up.

Conversely, for accountable care systems seeking to deliver outcome rather than activity goals within a fixed funding envelope, international examples such as the Canterbury Health Board in New Zealand have shown the rate of growth of hospital activity can be moderated by investing in services in the community. There is opportunity for general practice within accountable care systems, meaning active engagement could well benefit the profession as well as the local population.

General practice could choose to play the role of “strong voice around the table”. It could ensure it is involved in accountable care system decision making, and almost take on an LMC type role to ensure risk to practices is minimised and funding streams are maintained and, where possible, developed.

Or it could attempt to play a leading role. Accountable care systems are very much at the developmental stage. There is no fixed blueprint for how they will look or how they will operate. Active leadership now could drive the evolution of these systems to ensure they are built around core general practice and the delivery of joined up and effective prevention and out of hospital care.

2. What scale will the accountable care system operate at?

Equally, the answer to this question is not clear yet. On the one hand we have the devolution project in Manchester creating an accountable care system spanning the whole of Greater Manchester. On the other, the primary care home (PCH) initiative is promoting accountable care for populations of 30-50,000.

In most places, size has not been determined. It may be that “layers” emerge, with smaller local areas where they exist (maybe PCH size) feeding in to larger areas (maybe acute hospital catchment area size), in turn feeding into even larger areas (whole STP size, a la Manchester). What “feeding into” in this context means is anybody’s guess.

For general practice, the scale chosen is likely to be important. If an accountable care system operates at acute hospital catchment area size, general practice would need to be well led and organised to be able to match the voice of its acute counterpart. At STP level, how does it prevent its voice being drowned out by the multitude of other big voices around the table?

Even operating at a locality or neighbourhood level of 30-50,000, practices will need to find a way of working well together and creating a strong single voice. To influence the scale at which accountable care operates locally practices will need to be involved at an early stage of the discussions. Once final decisions are taken, they will be hard to undo.

3.How will general practice build the relationships it needs to participate in accountable care?

It is clear a system reliant on collaboration between providers is going to be a challenge for general practice which is currently organised into nearly 8,000 individual business units. Practices will first and foremost need to build relationships with each other. Some practices are merging themselves into a size that means they will individually be ready. Some are forming federations. For others the currently existing CCG localities may provide a platform practices can build on. Key here is if practices want accountable care systems to work for them, as opposed to simply becoming their new masters, the ability to work effectively together is undoubtedly task one.

Equally, GP groups (whether it be large practices, federations, or localities) have to find a way of working together. Ultimately there is going to be one GP voice in an accountable care system. For that voice to be effective it will need to be unified. The acute trust, for example, will have a single, clear voice. If general practice cannot create the same level of cohesion, its voice will be diluted, and influence correspondingly diminished.

Finally, GP groups will need to be able work collaboratively with other providers. The aim is not that these systems become the fora within which providers fight each other for their share of the fixed amount of funding available. Rather, it is for barriers between organisations to be removed and for more effective ways of delivering care to be developed for patients. This requires productive relationships based on trust. For general practice it will require strong local leadership that practices believe in and are prepared to back when decisions are made – there will not be the time or opportunity for every decision to go back to each practice for a vote.

The overriding message for general practice is accountable care is coming. As such, practices may want to consider how they want accountable care to work locally, to identify what role they want to play in both shaping and delivering this future, and to reflect on how ready they are for this new system which has significant implications for the future of general practice.

The impact of commissioning on general practice

At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future.   The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.

General Practice in 10 Years’ Time – Part 3

This is the third in the series of blogs where Ben asks the questions that he believes will shape the future of general practice. This week he asks

What Role Will Federations Play?

As with any look into the future, dipping into the past is a good place to start. Federations have changed significantly over the last ten or even twenty years. Post fundholding, and during the practice based commissioning years, federations were set up primarily to deliver services historically provided in hospital, in the community in order to generate an additional income stream for GPs and practices.

Since then, two things have materially impacted on the role of federations. First is the crisis that has engulfed general practice. Where federations historically operated at arm’s length from practices, they now have an important role in supporting member practices through the current challenges. This is a critical difference. It means the activities federations undertake are much closer to the delivery of core general practice e.g. visiting services, delivery of extended access, employing pharmacists and other new roles for practices. They have to work hard to ensure the cost of the additional layer of administration is offset by the value they bring to their members.

Second is the rise and fall of CCGs. At their inception they gave a powerful voice to general practice, as arbiters of how the NHS pound would be spent. No need, then, for federations to take on this role. Indeed, where they tried to assume this role, GPs were herded in and out of rooms to satisfy increasingly confusing conflict of interest requirements. But now power is shifting away from CCGs and away from commissioning. As CCGs get bigger, the local GP voice is getting smaller. As STPs and accountable care systems develop, the influence of general practice via commissioning continues to diminish.

Suddenly, we have a really clear role for federations: to support local practices to meet their current (and growing) challenges and to provide a strong voice for general practice as local systems move towards integrated models of working. Whereas in the past federations were something of an optional extra, it no longer feels like that. The challenges facing general practice and the wider integration agenda require an ability for practices to function coherently as a collective.

Federations provide that acceptable middle ground, where individual units can retain the independence and individuality they prize so highly, while at the same time gaining the benefits of joint working. They provide a vehicle for collective voice and collegiate working without necessarily requiring wide-scale restructuring into larger, formal organisations. Where trust levels grow between practices, and the ambitions for working together become greater, some are starting to move beyond loose federations into more formalised joint working arrangements, such as super practices.

Federations will play a key role in the development of general practice into the future. Where they are successful, owned by and adding value to practices while at the same time leading them through the integration agenda, they may well evolve into more formal partnership structures. Where leadership is weak and trust levels remain low, they may fall by the wayside, most likely to be taken over by more successful groups seeking to expand their footprint. Either way, we are already seeing well-developed federations able to play a leading role in local system integration plans. Moving forward, federations will have a critical role in both supporting the transformation of general practice into new sustainable ways of working, and shaping the role general practice plays within accountable care models and systems.

General Practice in 10 Years’ Time – Part 2

In the second of his blogs looking at the questions that will determine the future of general practice Ben asks

At What Scale Will General Practice Operate?

I find the answer “general practice needs to operate at greater scale” often precedes the question. Indeed, in many cases there is no sign of a question, it is simply presented as a statement of fact, as though 70 years of effective working at the current scale counts for nothing and there is no need to even make a case to support the statement.

As I have previously been at pains to point out, scale does not, of itself, automatically generate benefits for general practice. We only need to look at the graveyard of federation failures to know this to be true. Equally, the Nuffield Trust report “Is Bigger Better?” found instances where the quality of general practice reduced with increased size.

The authors of that report ultimately felt scale was better for general practice, but only where it is led by high quality leaders who understand the value general practice provides and work hard to preserve it. I have been fortunate enough through the podcast to be able to discuss with some of those leaders the rationale that sat behind their move to scale. What is striking is how different those rationales are. This is important, as it means there is not a single basis for general practice operating at scale. Further, it is the rationale for operating at scale that ultimately determines the answer to the question of at what scale general practice should operate.

There are seemingly two ends of the spectrum. At one end, the question is, “how do we create the efficiencies, voice and shared infrastructure to preserve and strengthen independent general practice”? This, for example, is broadly the question the super-practice Our Health Partnership (OHP) is seeking to answer.

They believe the optimum population coverage for their model is c500,000. This is based on each member practice contributing £2 per head, which creates a £1m budget to fund a management team. This is the size they believe is necessary to deliver real value. What is impressive about the model is it is maintaining a focus on working for the member practices (efficiencies), while at the same time creating a strong position within the local STP (voice).

At the other end of the spectrum, proponents of NAPC’s primary care home model advocate strongly for a population size of 30-50,000. Here the question is, “How can general practice really understand and best meet the specific needs of local communities, and retain and build on the sense of belonging that local communities have”? They believe if general practice operates beyond that size it cannot maintain the personal relationships fundamental to its success. Local needs vary so much that a service providing an average of the needs of two communities is in fact not meeting the needs of either.

Of course these two perspectives are not mutually exclusive. OHP want to build their organisation around specific geographical localities. Nav Chana, GP Chair of the NAPC, is clear a bigger population size might be required to create the infrastructure needed for these individual primary care home sites to deliver.

Futures are journeys not destinations. Beacon Medical Group is a great example of a practice on a journey. Already at 30,000, they have plans to scale significantly beyond that. But they understand what is important about general practice is continuity of care, and the ability for local areas to tailor services to the needs of their local population. So as they grow they are building on units of around 30,000, each with some degree of local freedom. Imposing a one size fits all operating model is not, in their view, going to work, even within a single practice.

General practice may be heading to a place where it operates at a large scale (over 100,000 population, maybe higher than 500,000) to create the new infrastructure it requires, while at the same time finding a way to retain some level of autonomy at individual locality level (30-50,000 population). But this concept of the journey, like the one that OHP and the Primary Care Home sites and Beacon Medical Group are all on, is the one that Rebecca Rosen and the authors of the “Is Bigger Better?” report believe to be critical. The most important question is not what size general practice is going to be, but rather how it is going to get there.

If you’d like to find out more about the future of general practice and meet some of the key voices in contemporary general practice (including Mark Newbold from OHP, Nav Chana Chair of the NAPC and Jonathan Cope from Beacon Medical Group) then why not buy a ticket to our first General Podcast LIVE event? For more information including a full programme and how to buy tickets visit our website here.

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