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.