GP Mergers – A Blessed Union?

In the first of a short series of guest blogs, Robert McCartney warns that the marriage of two practices will only be a success when there is a healthy pre-nuptial agreement between both parties.

Mergers are the ultimate form of marriage between GP practices. When they include the consolidation of the contract into a single patient list it becomes incredibly difficult, maybe impossible, to separate them again. As a consequence, the parties must understand the commitment they are entering into as there is no easy divorce.

During my recent podcast with Ben Gowland at Ockham Healthcare I stated that spending the time understanding and sharing a common vision of the future is essential. This applies to the relationship analogy. The most successful marriages are built upon a shared vision for their future, an understanding that there may be challenges but they will be overcome together and a trust that your partner will support you despite the occasional disagreements.

If the ‘soft’ merger elements linked to developing the relationships, like creating a shared vision and building a framework for the future of the partnership are rushed, the ‘hard’ formal merger steps may still happen but it increases the likelihood that the merger will fail.

Practices are currently under immense pressure and time is not a luxury many GPs have. Whereas a corporate merger may take months or even years to achieve, GP practices are looking to complete the process within a few months.

Fortunately, unlike a marriage there are some firm, definable objectives that all practices will be working towards. By ensuring that the parties focus on these at the earliest possible opportunity the ‘dating’ process can be accelerated with a reduced degree of risk.

The parties need to be willing to be forthcoming and ‘lay their cards on the table’ at an earlier stage than they may otherwise want to do. This openness is essential. In the past year, I have seen proposed mergers fall apart for a range of reasons based on people not being open until far too late in the process. This includes; forgetting significant funding repayment plans on properties; an unrealistic expectation as to equivalent sessional pay; and, despite comments to the contrary in the initial discussions, a complete refusal to consider using allied health professionals.

I have found that practices considering mergers have benefitted from having an independent third party facilitate and structure these discussions. This is especially important where time is of the essence. They are the pre-marriage counsellors focused on ensuring the merged practice is built on firm foundations.

For more information or if you would like support in any merger process you are considering or undertaking please do not hesitate to contact me.

Robert is Managing Director of McCartney Healthcare Associates Limited. He is an expert on practice mergers and this is the first of a short series of blogs he will be writing 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.

 

The Future of GP Visiting

In his latest blog Ben reflects on attempts to set up an outsourced GP visiting service and what it taught him about the way GP practices innovate.

A few years ago, when I was working in a GP federation, we set up a GP visiting service. The basic premise of the service was that, because GPs were so busy, they were not able to meet all the patient requests for visits. As a result, we hypothesised, patients were being admitted to hospital when an admission could potentially have been avoided if a visit had taken place. So we funded a pilot in which the out-of-hours service provided a GP to carry out visits during the day that they would not otherwise have been able to carry out.

Do you think it worked? It didn’t. The service was not fully utilised (despite only one GP being available for 30 practices). Uptake was limited to a relatively small number of practices, with many of the practices rarely, if ever, using the service. It was not possible to produce any correlation between the service itself and emergency admission rates (which instead stubbornly continued to rise), and, unsurprisingly, the pilot was stopped.

Contrast this with a practice I visited recently. There they have paramedics for 6 sessions a week, who carry out 5 or 6 visits a day, for a practice that in total undertakes between 7 and 10 visits a day. There are clear parameters in place for visits the paramedic will undertake and those that are best carried out by a GP, e.g. palliative care visits. The practice is extremely happy with the service and is soon to increase the number of paramedic sessions from 6 to 8.

In Shropshire the local out-of-hours provider Shropdoc has developed an Urgent Care Practitioner role in which staff with a paramedic, nursing or physician associate background are trained to be able to offer (amongst other things) home visits for GP practices. The role is proving extremely popular both with staff and practices alike. You can see a video of the service here.

A visit for a GP, with all of the travel involved, is a time consuming activity. While average consultation times may average 8-10 minutes, the total time required for a visit is at least double that, and often much more. Practices vary considerably in the number of visits they undertake. A recent comparison across five practices working in the same town revealed a fivefold difference in visit rates – varying from an average of 0.2 visits per 1000 patient population per day, to 1 visit per 1000 patient population per day.

So where did I go wrong with the GP visiting service we instituted, and what are others now doing right? I think I failed to fully understand visits are an integral part of the service a GP practice offers. Any attempts to change the way they are carried out must be fully owned and bought into by the GPs in the practice. Trying to “outsource” visits to a separate agency that does not know the patients is unlikely to work. A more successful approach is to use other roles, as long as they operate under the guidance of the GPs and not separate from them.

Equally, success in the redesign of GP visits cannot in isolation be measured by the number of emergency admissions. It is the continuity of care GP practices offer that will ultimately support patients to manage their conditions effectively. Freeing up scarce GP time to be deployed where it is needed most (which, paradoxically, will sometimes be in a patient’s home) is now a critical factor in enabling this, and would have been a much better measure of success.

It is hard to replace the long hours GPs work (at no extra cost) with a paramedic or nurse practitioner in a small, cash-strapped practice. As practices become bigger they have more freedom and more flexibility to experiment with different systems for triaging requests for visits, with the introduction of new roles, and with new ways of working for visits.

In my attempts to set up a visiting service I should have remembered that most successful change in general practice is generated within the practice itself, not imposed from outside. Changing the system for practice visits proved to be no exception. In future, as practices become larger they will have more capacity to test different ways of working and that is one of the reasons I established Ockham Healthcare; to support and promote the many innovations that will inevitably result.

The New Multispecialty Community Provider (MCP) contract and CCGs

In his second summary of the new MCP contract Ben looks at the likely impact on CCGs – and finds it is a case of “out with the new and in with the old”…

What does the new MCP contract mean for CCGs? Well, for all the range of documents published only two target specific groups: general practice (which was not surprising); and commissioners (which was). This was the first major clue that major upheaval is at hand.

The second clue was the way the document on MCPs and the commissioning system starts, “the new models… will not remove the established boundary between commissioning and provision. CCG statutory functions will not change”. You know trouble is coming when a document begins with what is not going to change.

The document then basically says while the statutory duties of CCGs will remain (so no acts of parliament required), most of what they actually do can (and will) be discharged through MCPs. It provides a list which states the only activities CCGs can undertake that MCPs can’t is: produce an annual commissioning plan; develop outcome measures and monitoring for MCPs; take responsibility for the overall performance of the local health care system; and create a contract to spread risk between the MCP and the CCG, as well as have responsibility for providers outside of the scope of the MCP. I.e. not much.

Interestingly it is in the finance document not the commissioning document where it is explicitly stated that management funding will transfer from the CCG to the new MCP: “an assessment will be made of current CCG and CSU spend on activities carried out by the MCP that will support commissioning. The value of this spend will transfer from CCG admin budgets to the MCP whole population budget”.

As a consequence we will need less CCGs, so the residual statutory functions can be carried out at lower cost. To really understand the following quote, insert “will have to” for “may want to” (it is only existing legislation that precludes the document from being more directive), “CCGs may want to consider whether the establishment of a new care model means that it would be appropriate to pool functions and management arrangements with neighbouring CCGs. This may be the case where an MCP or PACS cover the entirety or bulk of the CCG area; and where key CCG staff and capability will transfer to the new provider. In some cases the CCG may want to consider merger with another CCG.”

Even then CCGs won’t operate separately from the MCPs. “CCGs and new care model providers should maximise opportunities for making shared use of administrative resources. For example, creating and operating successful new care models will require a new set of information management and analytical approaches by both CCGs and providers… CCGs and new care model providers should look at how they might work together to develop a shared business intelligence capability rather than invest in potentially more costly separate functions. The same applies to other back office functions e.g. payroll.”

Of course, in the “virtual” MCP model, the changes are not so drastic. When I was looking at the draft of the alliance agreement for the virtual model, at first I was confused by the inclusion of commissioners on the alliance leadership team. Isn’t the point of an MCP that it is an integration of providers, deciding together how to deliver services? But, the document explains, they are included because their role is to make changes to underlying service contracts as a result of agreements within the alliance.

This makes sense in the context of MCPs taking over the lion’s share of what is currently considered commissioning. The only difference is in the virtual model the staff are still employed by the CCG and have not yet transferred their employment. In the partial and fully integrated models these staff will transfer and be responsible for “sub-contracting” between the MCP and its linked providers.

So MCPs carry out a range of commissioning functions, directly provide community services, include public health, and have a relationship based on section 75 agreements with social care. Is there something familiar here? Indeed, there is. The partially integrated model in particular is extremely similar to the (pre-transforming community services) primary care trusts. Everything above, plus a separate national GP contract but an ability to create local enhanced services, GPs as part of the management team (remember PECs?), and a clear role as system leader (integrator). For all the packaging of the new models of care as new and exciting, the new partially integrated model in particular will have to work hard to explain how it will be different from that particular version of the past.

In summary, the impact on commissioners of the formation of a local MCP is the end of a local CCG, and the creation of larger (more distant) CCGs focussed on a much narrower range of functions, and the creation of MCPs as integrated organisations that will undertake many of the existing commissioning functions, and which may or may not look like the old PCTs.

The New Multispecialty Community Provider (MCP) Contract

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

Top Five Countdown – Our Most Popular Podcasts of 2016

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…

 

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