18
jan
1

The New Multispecialty Community Provider (MCP) Contract

Posted by Blogs, The General Practice Blog1 Comment

Just before Christmas NHS England published a draft of the proposed new MCP contract, along with a set of supporting documentation (15 documents in all). In this latest Blog Ben Gowland considers the implications of these documents, and what it all means for general practice.

First, it is important to clarify this is not a new GP contract. The documentation clarifies it thus, “The (MCP) contract itself is not a contract with GP practices. GP participation with the MCP would be underpinned though an alliance agreement or the integration agreement in addition to the existing GMS/PMS/APMS contract, or through moving directly to work as employees for, or sub-contractors to, and MCP”. We will come to “alliance” and “integration” agreements shortly, but for now all talk of a “new GP contract” is misleading, because that is not what this is. Rather it is a contract with a new entity, an “MCP”.

So what is an MCP? It is a new provider, that brings together (“integrates”) existing providers. The range of these providers can vary, but it can include general practice, community trusts, social care, public health and specialised services. There are three different levels of “integration”, and the greater the integration, the greater the loss of independence for the participating organisations, and the greater the autonomy for the new MCP organisation. Along this spectrum there is a virtual MCP, a partially integrated MCP, and a fully integrated MCP. I will explore each of these in more detail below.

Virtual MCP. In this model no new organisation is actually formed and an MCP is not actually created. The existing contracts between commissioners and individual providers remain. The key difference is that an “alliance agreement” is put in place between the providers (including with the GP practices). The aim of this agreement is to “establish an improved financial, governance and contractual framework for the delivery of services”. There is a legal framework for the agreement supplied in the documentation (over 30 pages long), and it contains more specific actions than simply agreeing working together is a good idea. The more interesting things to note about it are: 1) the responsibility for establishing the alliance agreement in the first place lies with the providers wanting to create the virtual MCP; 2) an “alliance leadership team” is required, with representatives from all of the participating organisations that will make decisions in relation to the alliance; and 3) it can allow for GP practice participation in any local gain/loss mechanisms agreed for activity outside of the MCP (i.e. with the acute trust).

So while an MCP is not really created, the alliance agreement is still potentially powerful, as it creates a mechanism for collective decision making binding upon the members of the alliance, and as such represents the first step away from independence for participating GP practices. Equally it enables GP practices to positively benefit from gains made by the different organisations working together.

Partially Integrated MCP. In this model the contracts of the providers, with the exception of primary medical services, are brought together. So this time a new organisation, an MCP, is actually created, but separate contracts are held with general practice.

But it is not quite as simple as that. It is only the core contracts that are held separately from the MCP. The MCP contract requires it to ensure that its services and GMS/PMS are operationally integrated, to deliver seamless care for patients. Non-core income is clearly a mechanism to enable this, a point which is addressed thus, “We recognise that some GPs are concerned about the potential to lose non-core income and whether local enhanced services would be included in the MCP contract scope to ensure that their delivery is managed in an integrated way with other MCP services. If they are, local agreements could well see GPs delivering these, or additional services, as sub-contractors to the MCP. Local discussion will need to take account of these issues as GP participation in the model is agreed, including the maintenance of appropriate practice income”. So where there is a partially integrated MCP, practices will get core income from their existing commissioner (CCG or NHS England depending on level of delegation), and non-core income as a sub-contractor of the MCP.

Other financial impacts on practices are that practices can be offered an alternative to QOF to align practice incentives with that of the MCP. There may also be the opportunity to participate in the gain/loss share arrangements the MCP develops, which are essentially for levels of acute activity. Noteworthy here is that at one point the guidance states, “GPs in some areas are exploring the possibility of agreeing a gain-only agreement with the MCP”.

In this partially integrated model there is what it is described as an “integration agreement” between all the providers who are coming together to form the MCP, including the GP practices who are receiving core services via a separate contract. This is a much more directive document than the alliance agreement in the virtual model. This is because the document exists to ensure there is sufficient involvement of primary care, and what it does is create a framework for shared governance and decision making with the practices, and sets out the primary care contribution to the MCP model. A template integration agreement is included in the set of documents, and it contains elements such as, “all share in the savings generated by reduction in acute activity”, “GPs work towards reducing variation and unnecessary admissions (where appropriate) by agreeing a common set of protocols with the MCP”, “practices will make their booking system accessible to the MCP under local agreed protocols”, and “GPs will work with the MCP to achieve local primary access requirements”.

The partially integrated model therefore marks a further step away from the level of independence practices currently enjoy. The agreement is governed by an “integration leadership team”, on which all participating practices are represented, but which can decide and monitor how integration takes place. And again, “it will be for the MCP contract bidder to demonstrate that agreement has been reached with local practices on the Integration Agreement”.

Fully Integrated MCP. The third and most radical model is a new MCP organisation that includes core general practice, either via termination or a suspension of the current contracts. Immediately the whole ‘right to return’ question for existing GMS/PMS contracts raises its head, and this is dealt with in the document. Practices can reactivate their contracts either at expiry or termination of the MCP contract (which will be 10-15 years in length), or at regular two year intervals throughout its lifetime. The only sting in the tail is that, “A GP considering a return to GMS/PMS will need to articulate how the care the patient will receive from the new practice will compare to the care provided by the MCP”.

GPs and practice staff become salaried employees of the new MCP organisation, the terms of which they must negotiate directly with those leading the new MCP. They will receive rent for their premises via the funding that is first transferred to the MCP, and it will be up to the GPs to agree with the MCP the terms on which these payments will be passed on. The guidance states, “For GPs there may be an option to explore the sale of their premises to the MCP on mutually acceptable terms, though we would expect this to only take place in limited circumstances where there was clear value for money”. And in the fully integrated model indemnity cover for GPs and practice staff will be paid for by the MCP as the employing organisation.

A point to note on the fully integrated model is that the draft contract is based on APMS conditions. This means practices who choose to join will be giving up their existing GMS/PMS conditions and in the new model will be bound by APMS conditions. While you can argue it is the new MCP provider that is technically bound by these terms, the reality is that the expectations of provision of services of the GPs within the new organisation will be the delivery of what is in effect an APMS contract. Now the documentation does have a side note, stating, “In due course all such provisions will be amended to reflect or refer to the appropriate provisions of forthcoming Directions specific to MCP/PACS contracts”. I suspect the development of these terms may be a critical factor in the attractiveness or otherwise of the model, and a process GPs will very much want the GPC to be part of. As this process unfolds it will be interesting to see the extent to which the development of the fully integrated model actually represents a move away from a nationally negotiated GP contract.

So the fully integrated option means the end of independent general practice as we know it. While, as one of the documents states, “some GPs will prefer to move to the MCP as employees to improve their work life balance”, others are undoubtedly going to need some significant persuading.

Even those most evangelical about MCPs recognise the engagement of general practice is both critical and yet at the same time difficult to secure. A dedicated document is included on GP participation in an MCP. It comes up with the following reasons as to why GPs should consider it:

  • It can give GPs a more manageable and rewarding workload
  • It provides a contractual framework to share work between practices
  • It creates wider development opportunities for GPs that enable greater job satisfaction, including the opportunity to influence the wider system
  • It gives GPs greater influence over financial and staff resources, and over community services, and allows resources to be put where they are most needed
  • It gives access to a broader, more in-depth range of services in primary care settings
  • It will enable multidisciplinary team working that reduces handoffs for general practice
  • It has the potential to increase recruitment and improve retention for general practice by providing a structure for a larger primary care team

But with the promises of what the formation of CCGs could offer practices still ringing hollow in the ears of many GPs, and a commitment for much of this to happen anyway through the GPFV, none of this strikes me as overly convincing. It is either going to have provide a way out for practices who have had enough, or a route to really channelling additional resources into general practice if take up at any sort of significant scale is going to happen.

One route that would potentially give GPs more confidence this is going to happen is if the MCP organisation itself is owned by the GPs. This is referenced as an option, as a company limited by shares or a limited liability partnership. But new MCPs will need capital for start-up costs to deliver the infrastructure, working capital to pay salaries etc ahead of receipt of revenues, and contingency reserves. In the cash-strapped environment of the NHS it seems highly unlikely that many, if any, GP-owned models will emerge, as the incentives to put up this type of capital do not seem strong enough. Much more likely is that an existing NHS organisation will own or host the new MCP organisations. At best, we might see joint ventures between GP and NHS organisations.

The documentation refers on a number of occasions to “mixed economies”, where different practices from the same area choose different levels of sign up to the local MCP model, in particular with some choosing the partially integrated relationship and others the fully integrated. Where this happens it will be interesting to see the impact it has on the power of the voice of general practice, and whether it will be diminished. Even where local practices want to move together, it is not hard to envisage a situation where any failing practices or ones that return their list are “fully integrated” by commissioners at the earliest opportunity, meaning mixed economies are created anyway. Once the wheels are in motion, they may become difficult to stop.

GPs, then, will be considering the potential benefits on offer, and deciding whether the MCP route, with its associated costs to independence and the glimpse these documents provide to a future weighed down under the burden of NHS bureaucracy, is the best one for delivering them. Whilst there has been a growing disillusionment with independent practitioner status in recent years, support for it remains at well over 50%. My sense is the energy behind the primary care home movement, and the current shift towards collaboration and federation of practices, may represent not a step towards MCPs, but the creation of a more acceptable alternative to it, one that enables practices to build system relationships, take on new roles, change the way they manage demand, but at the same time maintain control over their own destiny.

Next week Ben will look at the implications of the new contract for CCGs

11
jan
0

Top Five Countdown – Our Most Popular Podcasts of 2016

Posted by Blogs, The General Practice BlogNo Comments

Incredibly, the Ben Gowland podcast, a weekly podcast looking at innovation and new ways of working in general practice, is approaching a year old. We are taking this opportunity to count down our Top Five most popular podcasts and so highlight some of those you might have missed. So far, we have published 45 episodes…but which ones make it into the Top Five?

In reverse order, the Top Five are…

At Number 5 it’s Rebecca Rosen with Lessons from large scale general practice

In July the Nuffield Trust published a report, “Is Bigger Better? Lessons for large scale general practice”. I talked to Rebecca Rosen, one of the authors, to try and get underneath the implications of the report. One of the things the report found was the limited impact at scale general practice had on quality, and it begged the question as to whether the current mindset that bigger is necessarily better holds up to closer scrutiny. So I was really interested to find out from Rebecca, a practicing GP herself, whether she herself thinks “bigger” general practice is indeed better.

At Number 4 we find Tracey Vell with Trialling the MCP Contract in Manchester

Much has been made (and continues to be made) about the introduction of the new MCP (multispecialty community provider) contract, and in particular why GP partners would give up their existing contracts for one that is time limited and potentially relegates them to the role of salaried employee. Tracey Vell is a GP, LMC chair in Manchester, and the lead general practice negotiator on the introduction of the MCP contract in Manchester, one of the six pilot areas for the new contract. It was only after this conversation that I really understood why GPs are even considering it.

And at Number 3 sits Neil Langridge with physiotherapists in general practice

The introduction of new roles into general practice makes the first of two appearances in our top five at number three. Neil Langridge, a consultant physiotherapist, describes his experience of working in a GP practice, and explains the value physiotherapists can deliver is not in the direct provision of physiotherapy within practices, but in delivering the initial assessment of patient needs. He explains how not only has he diverted considerable work from the GPs, but also the impact he has made on the referral rate to orthopaedics, making the idea attractive to both practices and CCGs alike.

Straight in at Number 2 with a bullet is Jeannie Watkins with Physician Associates

Despite only being published in December this podcast was the fastest downloaded of all, and in less than 3 weeks still made number 2 on our overall list. Having already spoken to real-life physician associates (PAs) Ria Agarwal and Andy King in episode 40 about their experiences working in general practice, in this episode I spoke to Jeannie Watkins, the RCP lead for PAs, about the pipeline of PAs coming through the system and the opportunities this creates for general practice. It turns out while many GPs find the idea of PAs difficult, those that work with them in practice can’t speak highly enough of them and the contribution they make!

And, at Number 1 we have Stewart Smith with the transformation of general practice in St Austell

The runaway leader in terms of number of downloads in 2016 is Dr Stewart Smith, talking about the amazing transformation of general practice in the Cornish town of St Austell. Trouble beset one of the practices in the town and eventually it had to give back its list. What follows is an incredible story of how the other practices in the town responded, and turned what was a crisis into an opportunity to create real transformation. Stewart describes how all the practices in the town merged and took the failing practice over. They then closed it, refurbished it, and reopened it as an acute care hub using a multidisciplinary team to see all the on the day demand from across the town. All within the space of a year!

It has been a fantastic first year for the podcast, and I have had the chance to talk to some amazing people, and find out that, contrary to what we are regularly told, innovation and new ways of working are alive and well in general practice!

We have some great guests lined up for 2017, including the GP behind one single change that is saving GPs up to an hour a day of administration time! You can subscribe to the podcast on iTunes, or you can become an Ockham subscriber (here) and we will send you the link to the podcast and this blog every week. And if you know of, or even are involved, in any exciting developments in general practice do get in touch, and maybe you can be the next guest on the podcast and find yourself in next year’s Top Five…

 

14
dec
0

Recent Developments in General Practice: Autumn 2016

Posted by Blogs, The General Practice BlogNo Comments

This week Ben Gowland turns his attention to our quarterly review of all that is new in general practice. And what a three months it’s been…

The planning guidance is out there

First off, the release of the NHS planning guidance. You can read our take on what this means for general practice, but essentially its distillation of the GP Forward View (GPFV) was an extra £3 a head for practices from CCGs in either 2017/18 or 2018/19 (or split across the two), and extra money for access from 2018 onwards (£3.34 per head in 2018/19 rising to £6 per head in 2019/20). CCGs have to produce a plan by 23rd December as to how they are going to implement (and fund!) the GPFV locally. We produced some thoughts for CCGs to ponder when crafting these plans, urging them to nurture and build on the seeds of local momentum rather than impose top down change.

Is operating at scale still an answer?

Many of these plans will inevitably include hopes of general practice operating at scale in future. We have seen some notable successes – City and Hackney GP Confederation put on a conference in November to share their achievements, and the country’s largest “super-practice”, Our Health Partnership in Birmingham, shared their progress over the last 6 months. However, all is not rosy in the at-scale garden. Horizon Health Choices Ltd in Bedfordshire, a 54 practice federation, went into liquidation proving yet again that scale itself is not the answer; but how you do it is. Our quick guide to introducing change in general practice will help anyone embarking on that particular journey.

Running with the GPFV

What of the GPFV? Well the latest allocations for the Estates and Technology Transformation Fund were released, and were generally less than expected and given a national prioritisation that differed from (and superseded) those made locally. We took time out to consider the trends in the world of primary care estates, where many GPs are looking for an exit route which the new models of care might just provide!

Interestingly, momentum in the GPFV implementation seems to have mainly come from internal productivity improvements within practices. CCGs received their share of funds for training medical assistants and GP receptionists, and (somewhat surprisingly?) it is having a huge impact. The 10 high impact changes, initially dismissed as a gimmick by most on first reading of the GPFV, are rapidly becoming one of the most useful parts of the document. Maybe even more surprisingly physician associates are starting to show the impact they can have on GP practices.

Collaborating with patients

Social prescribing, meanwhile, is gaining increasing credibility as a way of blurring the boundaries between primary health care and social care. Its most practical (and, in our view, finest) application is the development of leg clubs – using the need for medical treatment to create a sense of community and to tackle the social isolation leg ulcers can bring. New life has even been breathed into the often-dreaded patient participation group (PPG), with the development of virtual PPGs enabling much wider local participation in the practice than the traditional meeting format.

Sustaining and transforming…

The STP plans were also (finally!) published. The main complaint pre-publication was the lack of GP provider involvement on the STP boards. We looked at how general practice should be represented, and argue it is a choice GP practices should make for themselves as opposed to one imposed by the system. Given most of the STPs are reliant on a “transformation” of out of hospital care, lack of early involvement of general practice may be something areas come to rue later on.

New models of care

GP enthusiasm for MCPs has (at best) remained neutral over the last few months. Dudley CCG have published the first specification, but the promised draft MCP contract due in September has been put back until January, with growing murmurings of unrest from some of the practices involved. The second wave of primary care home sites was announced. Despite having no money attached, it was heavily subscribed. Even Simon Stevens acknowledged this is where the enthusiasm in general practice lies.

In fact one of the original primary care home rapid test sites, Beacon Medical Group, houses the newly acclaimed GP of the Year, Dr Jonathan Cope. Richly deserved. If you don’t know what he has been up to you can listen to him explain both how they transformed the way the practice works by introducing new roles , and how the practice has become a system integrator by building an impressive range of partnerships.

The legacy of CCGs

Simon Stevens hasn’t just spoken of the value of primary care homes. At the NAPC conference, as well as saying that QOF “was now nearing the end of its useful life”, he exhorted GPs to make general practice the CCG’s priority. If the legacy of an underfunded general practice remains after the period when GPs have been in charge of the money, and after an extra £2.4bn has been promised nationally, the implication was that it will be on GPs’ own hands.

What do you buy the GP who has everything?

But the highlight of the last few months has undoubtedly been the publication of our first book, “The Future of General Practice”. Described by one reviewer as, “probably the best summary of the options open to general practice that I have seen. It is… packed with examples, tips, lessons and practical guidance… I heartily recommend it to everyone interested in the options for GP development”. Christmas present – sorted.

Have a great Christmas!

7
dec
0

Welcome to the club – the rise of Leg Clubs

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Guest Blog by Amanda Brookes, Locality/Projects Manager – Bradford-On-Avon and Melksham

Anyone working in general practice cannot fail to be aware of the misery that leg ulcers bring to their patients; regular attendances and multiple medications, legs wrapped like the Michelin man, the discomfort and the smell. No wonder so many patients end up with depression and social isolation.

But, as I discovered, it doesn’t have to be that way.

In 2008 the practices I worked for established a provider company and won a bid to provide the Level 2 Leg Ulcer Contract to sixteen practices in West Wiltshire. As we developed our specialist team of nurses and HCAs it became clear to me that the treatment of leg ulcers was a neglected area and that patients were suffering unnecessarily; there had to be an alternative. At the same time, with my Business Manager head on, I was concerned with the costs of multiple attendances and the rising cost of specialist bandaging.

Although I am not a clinician, in 2010 I attended the annual conference of the Lindsay Leg Club Foundation and was immensely inspired by Ellie Lindsay OBE and the model for Leg Clubs which she had developed in the mid-nineties.

Ellie was an ex-District Nurse and had set up around 25 Leg Clubs, led by District Nurses who invite housebound, potentially socially isolated patients into a social setting for care and chat. Her results on healing and recurrence rates were excellent. I invited her to talk to our Leg Ulcer team and we were so impressed we began talks locally on how this model might be made to work in primary care.

For those who don’t know, a Leg Club is an evidence-based initiative which provides community-based treatment, health promotion, education, ongoing care and social activities for people of all age groups who are experiencing leg-related problems.

Following a merger with two smaller practices, our original patient base of 14,000 grew to over 20,000 which resulted in more patients with leg ulcers and a lack of space. This was the ideal push we needed and we began to pursue the Leg Club model in earnest.

The doctors and nurses I worked with were incredibly enthusiastic but it was difficult to gain interest from those who held the purse strings. So we began a very time-consuming and frustrating hunt for sources of money. It was at this time, after running a number of community events with charitable organisations, that I came to the realisation that leg ulcers are not sexy!

It became bit of a running joke with colleagues, every-time I met anyone who could help or would listen, I talked Leg Clubs! I’m afraid I became mildly obsessed and evangelical but it paid off in the end when the Friends of Bradford on Avon Community Health Care gave me £12,000 of funding. Others then followed.

And it turns out the model can very much be made to work in primary care. General practice nurses provide the drop-in clinical support (through six stations) in a local community hall and we have a Doppler machine as part of a patient’s first assessment. A committee made up of Leg Club members is in control of the social side which includes activities such as a Balance and Falls Class, structured short walks program, an arts group, access to a podiatrist, support from a care co-ordinator, dementia advisor and ad hoc speakers such as Carers Support and Age UK – all of which remain accessible to members even once their legs are healed.

We estimate that members coming to the Leg Club have saved the practice around 20 appointments a week. The well-leg regime has no funds attached – but as our recurrence rates fell over two years from 75% to 25% there is evidence that it is a cost effective model. Membership is at 600, and legs are now healed in an average of 12 weeks, whereas in 2014 it was 19-24 weeks.

It is a constant battle to raise funds for the social side but we have regular fund raising events and local industry partners are very important.

The patients love attending the Club and the nurses love it also because they are not constricted by time; consequently the atmosphere is positive and fun. The practice likes it because it has reduced the number of times this group of patients come to the surgery and in many cases, their mental wellbeing has improved.

If you are thinking of setting up a Leg Club yourself then I strongly recommend you contact the Lindsay Leg Club Foundation (information at www.legclub.org– and you’ll see us on there!)

There is a lot of planning, fundraising and awareness-raising to be done before a Leg Club opens. There needs to be a Champion or Lead with the passion to take this project forward; it’s hard work and needs on-going support once the club opens. Nurses need to be trained in the infection control standards for community based care as well as admin staff to learn how the patient record and audits are produced. The Leg Club Foundation carries out an audit once a year by an independent clinical consultant and keeps a check that all the standards are being met and are safe. The Club submits weekly audits and any corrections are fed back to us to rectify.

I know I have become evangelical about Leg Clubs, but for a reason. They do work clinically, they make business sense and they provide a better service for patients. But if you are still not convinced you can either watch our short video on the subject here or contact me via email at amanda.brookes@nhs.net

30
nov
0

Where to start with CCG GPFV plans

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The crisis in general practice has led to individual practices making changes, on their own at first and then increasingly together.  CCGs should be facilitating this process through their GPFV plans rather than introducing big picture change, argues Ben Gowland.

There is something going on in general practice. Change is afoot. While nationally all of the talk and rhetoric is around STPs, new models of care and operating at scale, practices seem to be taking a different approach. CCGs should take note.

At the risk of stating the obvious, general practice is not one organisation. It is 7800 independent, individual business units, all operating in their own way. While the contract they deliver against is (essentially) a national one, how they choose to deliver against that contract is up to them. And it varies significantly. No two practices work in the same way.

Despite its obvious drawbacks, this variation has created a huge opportunity. For every single practice there are better ways they could be doing at least some things. For some practices there are better ways they could be doing most things. And as the crisis in general practice has started to bite, the response has been (as is the way of general practice) pragmatic. Practices are starting to focus on how they do things internally. “How we have always done things around here” is no longer good enough, because it no longer works.

What is starting to emerge are changes with quite astonishing results. Hours of administration time removed because of changes to the way documents are handled. Huge reductions in DNA rates because of changes to the way appointments, and cancellations, are handled. Swathes of clinical work moved from GPs as a result of the introduction of different types of clinician into the practice team. New types of appointment creating more efficient ways of meeting the ever increasing demand. The lives of the duty doctors being literally transformed by internal re-shaping of how appointments are handled.

Making the first real change is always the most difficult. But once achieved it often creates a thirst for more. Practices that were previously impenetrable islands suddenly let the drawbridge down, keen to share their success with others, and are newly open to learning from the success of others. This sharing brings mutual success, builds trust and strengthens relationships that had grown cold through the winter of the crisis.

And out of this trust and these relationships further improvements and changes are found to be possible. Accountancy fees, indemnity fees, regulation costs (and more) are starting to be reduced by practices working together. More new roles are introduced. GP-led multidisciplinary teams enable practices to tackle the workload in different ways, freeing up GP time for the patients who need it most. Once the rock is moving, it develops pace, energy and impact, and more and more is achieved.

All around the country (but not everywhere) this is starting to happen. The hard bit is the first step – recognising there are other ways to do things, and then making the first change happen inside the practice. Talking about big picture change in locality or CCG meetings is not what is important. Arguments about the rights or wrongs of MCPs won’t help. It is only doing something differently at the individual practice level that has an impact, that can get things moving.

Which brings me to CCG GPFV plans. General practice is still in crisis. Don’t turn the plan into a strategic template for the introduction of MCPs, or a way to fulfil a requirement for 7 day working when 5 days is currently out of reach, or the creation of complex bidding processes for limited pots of money in the name of “equity”. Instead, use the plans to help practices take the first step, or if they have taken the first step the second, or the third, or whichever is the next step to build the momentum local practices need to find a way out of their current predicament.

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