A new lease of life for APMS Contracts

General Practice has never really liked Alternative Provider Medical Services (APMS) contracts. This is because they are the only GP contracts that can be negotiated with those who are not NHS GPs, such as foundation trusts and commercial organisations. But, writes Ben Gowland, they may be about to experience a resurgence…

APMS contracts were introduced really as a mechanism to enable NHS commissioners to market test General Practice against the private sector. But fears the APMS contract was going to lead to the privatisation of General Practice proved unfounded. Research by The King’s Fund[1] found use of APMS contracts by PCTs was limited and very few APMS contracts had been awarded to independent providers.

There is no specified maximum contract length for an APMS contract, but they were typically awarded for a five-year period. This is in stark contrast to the unlimited contract length of the main GMS and PMS contracts. This drew criticism from the profession as providers would not make long term investments, or tackle long-standing problems such as premises leases. A 2015 study published in the Journal of the Royal Society of Medicine found APMS practices provided worse quality care than practices on GMS or PMS contracts, even when demographic differences such as age and deprivation were taken into account.

But change is afoot. A hospital foundation trust in Chesterfield has been awarded a 15-year APMS contract to run three GP practices serving more than 20,000 patients in Derbyshire. 15 years, and with an option to extend for a further 3 years! The APMS directions do not specify a maximum contract length and a contract exceeding 5 years can be agreed locally, but even a few years ago this would have been unheard of.

Now, as with all aspects of integration, using the APMS contract in this way creates issues for commissioners. The 2013 APMS directions[2] state the APMS contractor is required to be a member of the CCG. So by deduction Chesterfield Royal Hospital must now be a member of the local CCG. Equally, when the APMS contractor makes a decision to refer a patient it must ‘do so without regard to its own financial interests’. Choice and integration are not easy bedfellows.

But North Derbyshire CCG are not alone. Other CCGs, e.g. Blackpool CCG[3], have also been considering APMS contracts of 10-15 years (interestingly the same length as the new multispecialty provider, or MCP, contract). Clearly, something has changed.

The world has shifted since 2004, when APMS contracts were first introduced. Then the focus was on competition and market testing. In our post-Five-Year-Forward-View-world there is a new game in town: integration. APMS contracts are changing from a tool to enable competition to a tool to enable integration. Hence the sudden shift from short to much longer term contract durations. Blackpool CCG explicitly stated that ‘longer term contracts offer stability and an incentive for providers to participate/engage in CCG strategy, new models of working and integration in neighbourhoods’.

Suddenly APMS contracts have a new lease of life, as an enabler to integration. The 15 year APMS contract award in Chesterfield was met with local LMC approval. General Practice antibodies to the APMS contract appear to be dissipating (although lingering concerns over the contract value relative to GMS/PMS inevitably remain). Extending the term of the APMS contract, keeping it within the NHS ‘family’, and using it as a building block for the new models of care, mean it may be about to become much more prevalent than ever before.

[1] Walsh N, Maybin J, Lewis R (2007). ‘So where are the alternative providers in primary care?’ British Journal of Healthcare Management, vol 13, no 2, pp 43–36.


[3] http://blackpoolccg.nhs.uk/wp-content/uploads/2015/10/Item-6-APMS-Paper-Oct-PCCC.pdf

How to find the GPFV money

The money that sits behind the General Practice Forward View (GPFV) is proving elusive. We seem to be in a place where lots of money has been promised, and in a very British attempt not to appear ungrateful no one is really asking where it is. Instead we are just hoping it will materialise. I have now asked a range of people about it, some in practices, some in CCGs, and some in national roles, and not a single one is clear when or where this money is coming.

So here at Ockham Healthcare towers, we have identified 5 things to watch out for if you want to find the missing millions promised in the GPFV:

  1. Watch out for the 2017/18 core contract rise. This might sound obvious, but this is actually going be the most important announcement for General Practice, as we will get our first sense of how much of the promised additional £2.4bn will actually arrive into core contracts. In NHS England’s business plan published in December last year they had indicated a 4.0% uplift for next year, so that would be a good benchmark to monitor the actual rise against.
  2. Watch out for the publication of the local Sustainability and Transformation Plan (STP). NHS transformation money has been given to the STP areas, and in the guidance sent to them it said the allocated funding included money for, “taking forward the programmes set out in GPFV and delivering extended GP access”. This means GPFV money has been given to the STP areas, and it is their job to say how they are going to use it.
  3. Watch out for how much extra investment goes into the new MCP contract. We now know the multispecialty community provider (MCP) contract is not for General Practice alone, it is for all the providers of community services in an area. If investing in the MCP contract is used synonymously for investing in General Practice, there is a high risk that only a proportion of that money will find its way through to individual practices.
  4. Watch out for your CCGs commissioning intentions and plan for next year. The RCGP are optimistic about this. They believe that over the next 5 years CCGs will invest 10%-20% more in General Practice, reaching somewhere between £184 and £368M by 2020/21. Very crudely that is £1-£2M extra per CCG, which would mean growth of £200k-£400k each year. So review next year’s plan, and see if you can find it.
  5. Watch out for next year’s Better Care Fund (BCF) plan. Again, this was trailed in the GPFV and the RCGP have picked up on it, thinking that more money will come from that fund into General Practice. Next year’s BCF plans will indicate whether the RCGP’s faith in them is justified.

Details from each of these areas will be released in the next 6 months, which means soon (hopefully!) we will know exactly how the money is going to come to General Practice. Then we can make a better assessment of the impact it is going to make.

One tip for practices looking to maximise their own share of the money. There are a lot of different pots of funding. As a minimum we know that practices can potentially access pots of funding for: practice resilience programme; clinical pharmacists; practice manager development; practice nurse development; CCG practice transformational support; on-line consultation implementation; releasing time for patients programme; mental health workers; and further capital allocations. Get together with other practices and identify or employ someone whose job is to look out for pots of money that become available and write bids for all the practices. It won’t take long before they have already paid for themselves!

The new MCP Contract Framework: more important than the GPFV

The recent NHS England document, “The Multispecialty Community Provider (MCP) emerging care model and contract framework” (which you can find here), is in Ben Gowland’s view a more important document about the future of General Practice than the General Practice Forward View (GPFV). He explains why.

The document describes how NHS England sees the future of General Practice. At the same time, the document is not written specifically about General Practice. This is because it is about MCPs, and an MCP is not a form of General Practice. Rather it is a new organisational form that includes General Practice. As such, it potentially represents the end of the independent contractor model of General Practice.

That’s a lot to take in, but I don’t think I am overstating it. I read the document expecting to find out more about the new voluntary GP contract that the then Prime Minister David Cameron had unexpectedly announced last year. But it turns out there is no new GP contract. The new contract is for MCPs, a new form of organisational entity,

An MCP is what it says it is – a multispecialty, community-based, provider, of a new care model. It is a new type of integrated provider. It is not a new form of practice-based commissioning, total purchasing or GP multi-fund, or the recreation of a primary care trust (PCT). An MCP combines the delivery of primary care and community-based health and care services – not just planning and budgets. It also incorporates a much wider range of services and specialists wherever that is the best thing to do.” p5.

General practice will become only one part of this new bigger organisation. What the document does is work through some of the detail of the new MCPs, and in particular how they will be contracted. While the primary focus of the document is not General Practice, the implications for General Practice are huge.

Now, before panic sets in, the model is entirely voluntary for General Practice. The document clearly states, “Under no outcome would GPs lose their right to continue to provide primary medical services against their will” p29. But that said, what exactly does the document say about the relationship between the new MCPs and General Practice?

First there is what looks like a ‘pre-qualifying’ phase. General Practice has to operate at a population level of at least 30,000, which, the document says, “is a natural first step towards an MCP, for example via super practices or GP federations” p20. It then says, “Working in groups of at least 30,000 patients enables general practice to be commissioned to take on new services and funding set out in the General Practice Forward View. These could include the provision of additional access, co-funding for the introduction of pharmacists within general practice, or infrastructure investment.”

I don’t know what to make of this. It hints the new investment in General Practice is only going to be available to groups operating at this scale, but maybe I am reading too much into it.

There are three types of contractual relationship GPs can have with an MCP. The first is through a “virtual” MCP contract. Here, the existing individual contracts of the GP practices and other providers of community services remain separate, but are then overlaid with what is essentially an agreement between all of them in which, according to the document, they “could establish a shared vision and a commitment to managing resources together, as well as clear governance and gain/risk sharing arrangements, together with an agreement about how services will be delivered operationally” p20.

The second type of MCP contract is described as “partially integrated”. Essentially all provider contracts are brought into a new single MCP contract, except the GP contracts. It could include elements of the GP contract, e.g. QOF, DES’s “by agreement”. These agreements could, “break down barriers and commit GPs to new ways of working (e.g. by working at scale, redesigning the workforce, and developing operational protocols)” p27.

The third and final type of MCP contract is “fully integrated”. All the provider contracts are brought into a new single contract, including the GP contracts. The contract will be 10-15 years in duration, and the DH has been asked to change legislation to create an option to enable GPs to return to G/PMS arrangements (p27). It will have a performance element that replaces QOF and CQUINs of approximately 10% of the contract value. The contract will be for the existing value of the commissioner spend for the services included for the population served. It will have gain/risk share arrangements that are yet to be determined.

Can GPs own and run an MCP organisation, and hold a “fully integrated” MCP contract? It would appear this option will be to open to very few. An MCP can in theory be a Limited Liability Partnership (LLP), a Community Interest Company (CIC), or a limited company. GPs could be partners or shareholders in these organisations, and as such be direct owners of the company. But not on their own, “it is quite likely that many existing organisations that deliver part of the proposed MCP service scope will be unable in isolation to be credible holders of a fully integrated MCP contract, and they will need to forge new partnerships” (p25). Only “stronger” federations or super-practices, the document says, “could then seek to develop into credible bidders” for MCP contracts (p20). The clear implication is very few GP organisations of any type will even be eligible. The document itself concludes, “Given that MCPs will be responsible for out of hospital services, the natural application of this option would be with existing Community Trusts or FTs” (p26).

And in this scenario (established in the document as the most likely) what happens to the GPs? Well, they either become employees of the new MCP, or subcontractors or independent contractors operating under a clinical chambers model. And what will their salary be? That will be up to the MCP, because, “there is no single new “contract” for individual GPs wanting to be part of an MCP arrangement” p28.

At present 8% of the country is covered by MCPs (although it should be said that 0% is currently covered by any sort of MCP contractual agreement). By next year the document states that national coverage will expand to 25%. The expectation is that a quarter of the country, and therefore a quarter of General Practice, will by next year will at least be moving towards these new contractual agreements.

As with any radical new proposal, the document generates more questions than answers. But the overriding question I am left with is where do the incentives lie for General Practice? Remember it is voluntary, so it needs incentives. Maybe the model of an MCP, with its focus on population health and freedom to innovate, will be attractive enough for some. Maybe for others it will provide the way out they have been looking for (“GPs participating in an MCP may leave their current contractual arrangements permanently. They might contribute their existing GP partnership for a share of the MCP partnership or equity” p27). Maybe there will be freedom within the new contractual arrangements for each practice or groups of practices to create an outcome that is beneficial for them. Maybe it will be the only way to access the additional £2.4bn General Practice has been promised and needs to survive. Maybe I have missed something…

The document presents a new future for General Practice, as part of a wider team delivering care for a local population through an MCP. But it is a dense and difficult document, not targeted specifically at GPs – written instead I would say with GPs in mind. General Practice may only be one part of an MCP, but an MCP potentially represents the whole of the future for General Practice, which is why this document is so important.

How CCGs can partner with locum GP Chambers

In the third of our series of articles on CCGs and local locum GP chambers, we explore how CCGs can work with the local chambers once it has been established, and how the partnership between the two can benefit local practices, patients and the wider healthcare system.

Once a chambers has been established locally, CCGs can partner with them to put together a programme to offer training and other services to local practices. This programme can include:

Practice Improvement. The chambers can collect regular feedback on each practice from its GP locums and sensitively provide constructive feedback to help practices improve their working relationship with its clinicians. It can also play an active role in identifying local best practice and spreading it to other areas (e.g. appointment systems, DNA policies and procedures etc.)

Backfill to create GP time for CCG business. GPs often cannot attend CCG meetings because no locums are available. Local locum GP chambers can work in partnership with the CCG and use their local workforce intelligence to ensure these meetings are organised at a date and time when backfill can be arranged.

Practice Manager Training. The Chambers can put on workshops for practice managers on how to make the best use of locum GPs, including elements such as getting their feedback on your practice, how to make sure locums want to keep working at your practice, avoiding risk and complaints, and spreading best practice.

GP Locum Training. The chambers can provide training for locums to include elements such as high quality referrals, improved prescribing, supporting continuity by writing better notes, being involved in clinical governance, increasing effectiveness as a locum by giving better feedback, engaging with the practice, risk management and clinical handover.

Workforce Planning. Commissioners and the chambers working together proactively can ensure an effective use of the local GP locum workforce to help manage and avoid workforce issues, including holidays, sickness, winter, out of hours and weekends.

Service Provision. As with other GPs, many GP locums have specialist skills e.g. women’s health, dermatology etc. As locum GPs these skills are often under-utilised, but within the chambers model, these skills can easily be deployed across the CCG when and where they’re needed.

Direct locum Involvement in CCGs. CCGs and local locum GP chambers can work together to better involve the dedicated pool of flexible locum GPs so that they are more involved with commissioning, especially building on their experience in working in lots of different practices across the patch.

Some local GP locum chambers may be prepared to go a step further, and consider a scheme for the chambers to support local General Practice. In such a scheme the CCG would contribute the administration costs of the running of the chambers (rather than this being paid directly by the locum GPs themselves). In return the locums would offer to meet specific needs the CCG has. The table below provides an illustration of some of the potential elements of this scheme.

GP locums open up their availability five months in advance Often, GP locums will only make themselves available one month in advance. Incentivising them to open their availability to 5 months would enable better and longer term planning by local practices.
Practice-blacklist amnesty A locum agrees a trial of returning to work in a practice they have otherwise chosen not to work in. Appropriate safeguards are agreed in advance, and feedback is given after the assignment to identify issues and solutions.
At busy times (Christmas, Easter etc), enter into a ‘holding pattern’ Typically, well organised practices book well in advance, and struggling practices book when they are ‘desperate’. The ‘holding pattern’ would entail a commitment by the GP locum to work, but the location is only announced when local practices have been assessed on a needs basis by the commissioner.
Minimum commitment Locums agree to a minimum level of service e.g. four sessions per week.
Time ringfence A commitment is made by the locum to give first choice to the sponsoring CCG up until a set time period, after which the locum can make themselves available elsewhere.
Backfill If a practice is in crisis, local experienced partners can be deployed to the failing practice, whilst the chambers deploys a group of chambers locums in the donor practice to reduce loss of continuity.
Attendance at clinical governance meeting Already a requirement of many chambers, regular attendance at internal clinical governance meetings to discuss significant events, complaints and feedback about practices.

 Whilst such a scheme is not currently in existence, the Chairman of the National Association of Sessional GPs (NASGP) Dr Richard Fieldhouse believes the potential of such a scheme to be huge. He says, “As a system we consistently fail to make the most of the opportunity that locum GPs provide. The Chambers model enables effective partnerships to be developed between commissioners and locum GPs, and a scheme like this is the logical next step”.

Does the PACS model mean the takeover of General Practice by the local hospital?

When the new models of care were first introduced in the Five Year Forward View, there was concern in some quarters of General Practice that the PACS model (Primary and Acute Care Systems) could herald the takeover of General Practice by local hospitals. Ben observes that this is far from what is actually happening…

When I read of the Symphony Programme in Yeovil, one of the PACS vanguards, it looked like this indeed was what was happening. A number of local practices – initially 3, then 6, and potentially 10 – were reportedly joining a company, Symphony Healthcare Services, which is wholly owned by Yeovil hospital.

I contacted Dr Berge Balian, a GP and the Chair of the South Somerset Symphony Programme Board, to find out whether the rumours were true, and if so why the local GP practices were allowing this to happen. We spoke, and what I discovered was surprising. He kindly agreed that we could use the conversation as a podcast, which you can find here.

The first surprising point is the focus on General Practice, and developing it to play a leading, sustainable role in the delivery of care, through an enhanced primary care model. This includes incorporating health coaches within practices, as well as extending the care team to include mental health, pharmacy, and therapists.

The second is the starting point for working together: both General Practice and the acute hospital are experiencing the same pressures, of demand, recruitment, and finances. There was a realisation in conversations between the two that by combining they could more effectively meet these problems. As Berge puts it, ‘The ultimate outcome is that the hospital is going to shrink’, as it focuses on doing only what it absolutely needs to do. Working together provides the mechanism for moving resources, whether money or personnel, from secondary to primary care, in ways that could alleviate pressure on both sides.

Berge was an LMC chair. He knows General Practice inside out, and has its best interests at heart. Inspired by the vision of the Chief Executive at Yeovil Hospital he took on a role there as Associate Medical Director for Primary Care. Together with the Chief Executive they began building bridges between the hospital and the local practices. Berge knew change in General Practice starts by building trust, and he recounts 18 months of conversations that they had with all of the local practices, strengthening relationships and ironing out problems. A key part of the battle, Berge recounted, was convincing the practices this was not a clandestine way to negatively impact General Practice.

What happened next was most interesting. A number of local practices became so overwhelmed with their own problems they approached the hospital directly wanting to formally merge with them. The hospital considered this, but Berge wanted to ensure the valuable G/PMS contracts, which are contracts in perpetuity, were protected. As a result, they set up a complicated set of arrangements (under the banner of Symphony Healthcare Services) that means the existing contract is preserved, the organisation is at arms-length from the hospital, it is led by primary care clinicians, and the lead partners have a ‘right to return’ to their original contracts in future.

Impressed by the hospital’s commitment to making this work for General Practice, another 6 or 7 practices have expressed an interest in fully integrating with the hospital through Symphony Healthcare Services. And not just the ones in trouble. As Berge says,

About half are motivated by some challenges they are having, but another half really just see the future of General Practice being in a different model to the historical smaller partnership model.”

The integration of the practices with the hospital is built on what are described as “three pillars”: to preserve the individual identity of each practice; to share administrative and back office functions across the practices and the hospital; and to redesign the healthcare system, through the enhanced primary care model and shifting how care is provided for patients.

When asked about the future, what Berge sees as key is keeping primary care at the centre. His focus is on ensuring that those practices that have chosen not to ‘integrate’ with the hospital will stay at the centre of this work, shaping how resources are shifted from secondary to primary care.

At the end of the conversation I was not left thinking the local hospital had taken over local General Practice. Rather I was impressed by the way the hospital had enabled integration to take place by working to meet the needs of the local practices, and ensuring practices remain in the driving seat.

Page 69 of 73