Commissioners must drive but leave providers to steer new care models

6 October 2017

Commissioners can prompt local providers to embrace new service models and accountable care, according to Hill Dickinson partner Robert McGough.

Addressing a recent PCC event on contracting for new care models, McGough said: “As a commissioner you can drive provider behaviour – for example by saying ‘we want one diabetes contract’ or you want to commission one accountable care provider. Then providers will have to think about working together and how such a structure could operate. But the providers should be deciding the right model for them to collaborate – or indeed whether to collaborate.

“The procurement regulations are supportive of appropriate pre-procurement engagement with the market.”

Asked how long it would take us to see an NHS ACO, McGough suggested that some ACOs operated as prime contractor models led by foundation trusts could potentially be up and running by next April given they already had a statutory footing and significant freedoms. By contrast, he suggested that new collaborations, where there are complex configurations of providers and/or little track record of organisations working together, could face a journey lasting several years.

Legal requirements to consult the public could also be time-consuming where they are triggered as part of a new care model, he cautioned.

Referring to NHS England’s recent publication of three potential integrated models – virtual, partial and full integration – McGough questioned whether GPs would always be the right group to lead an MCP or ACO. Under new consultation proposals GPs can set aside their GMS or PMS contract and become salaried employees of the new provider organisation but could reactivate their contract later (see ). Given this “right to return”, McGough suggested, having GPs at the centre of the management structure risked destabilising the MCP if some of the participating practices exercised that right.

While the decision on leadership of the provider organisation would be shaped by factors such as management of risk and tax, employment and pension issues, McGough said that a further determinant could be what services the MCP will actually provide and the position of primary care.

The evolving ACO contract is similar to the current NHS standard contract. However, important changes include updated primary care directions that allow primary medical services to be commissioned in a streamlined way within the ACO contract, alongside a range of other services across different settings.

To assuage concerns at the potential risks associated with larger and longer contracts, commissioners are being handed some additional powers through the new contract to ameliorate the impact if a provider runs into problems. These include additional powers for commissioners in relation to sub-contractors, extended transparency and reporting requirements, pre-conditions (where relevant) around the distribution of profits and the ability to include break clauses to help commissioners and providers response to uncertain future developments. New accountability and regulatory arrangements are also being developed.

Among the changes already emerging in early accountable care contracting arrangements are the shifting to new provider organisations of some activities previously carried out by commissioners.

Overall responsibility for those functions remained with clinical commissioning groups (CCGs).

Commissioners are asking providers to do things CCGs may previously have done. CCGs and providers have certain statutory duties which cannot be transferred. Some commissioners are talking about the ACO managing elements of their commissioning arrangements, for example supporting CCGs in their duties to develop population health planning, managing resources, addressing health inequalities and risk stratification of the population to enable services to be appropriately directed.

Local arrangements such as the transfer of commissioning activities would be subject to the integrated support and assurance process (ISAP) run by NHS England and NHS Improvement to oversee the awards of novel contracts. This process is intended to give all parties opportunities to assess their readiness to sign a contract. ISAP is developed to provide assurance at specified points throughout the procurement process. The whole contract award process could typically therefore take 12 to 18 months.

[related articles]

Getting GPs on board remains a big issue for accountable care organisations

NHS England’s proposed contractual approaches for accountable care models

Accountable care organisations need support to get GPs’ pay right

Support updates Our news

Latest News

The sexual orientation monitoring information standard

17 October 2017

NHS England has developed a sexual orientation monitoring (SOM) information standard with help from LGBT Foundation.

It is designed to allow policy makers, commissioners and providers to identify health risks and address the health inequalities for people who are lesbian, gay or bisexual.

Read More

Should local authorities be penalised for delayed transfers of care?

17 October 2017

According to a report in the HSJ, 32 local authorities have been warned by ministers that they face funding cuts if they don't improve the services that support patients to leave hospital. Will punitive action help or will it cause more hardship? Vote on the NHS Networks poll at www.networks.nhs.uk

Read More

Dealing with difficult people and situations – courageous conversations

17 October 2017

The session on 31 January in Birmingham, 8 February in London and 13 March in Manchester looks at workplace challenges and fears, what causes stress in these difficult situations, and how to cope with them. We discuss how to build personal resilience and develop assertiveness skills, followed by a session on courageous conversations – things to consider and top tips. We also spend time testing out some difficult conversations, to help you to understand what to do when you face resistance or hostility.

Read More

NHS England’s revised policy and guidance manual for primary medical services 2017

17 October 2017

NHS England, with support from Primary Care Commissioning (PCC), is arranging a number of events to inform primary medical services commissioners of key points and updates contained in the revised policy and guidance manual due in autumn 2017. There is no fee for commissioners.

This event on 21 November in Birmingham, 23 November in Bristol, 28 November in London, 5 December in 5 December in London and 7 December in Manchester covers the key aspects of the general duties under delegation, primary care commissioning, contracts and how to apply changes if or when necessary. These are outlined in NHS England’s recently revised guidance entitled Primary Medical Care Policy and Guidance Manual (PGM). This includes the regulations required to manage and govern these contracts properly.

Read More

Clinical radiology: UK workforce census 2016 report

16 October 2017

This report argues that the ongoing shortage of imaging doctors will result in late hospital diagnoses and delayed scan results for patients. It finds that the NHS paid out an estimated £88 million for out-of-hours reporting of x-rays and scans, while nearly two-thirds of vacant radiologist posts sat empty for 12 months or more.

Read More