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

6 October 2017

In August NHS England published documents setting out current thinking on the relationship between GPs, practices and various forms of accountable care organisations (ACOs). The papers included a new version of the ACO contract that will evolve further over the coming months.

A key issue is how GPs can be encouraged to participate in integrated delivery models.

The NHS England documents set out three levels of possible integration of GP practices into the new MCP/ACO provider organisation: virtual, partial and full.

The move towards the ACO model is being shaped by the aspiration to put in place long term outcomes based contracts that incentivise providers to invest in population health improvement.

Ensuring there are appropriate methods for GP involvement is part of a range of work that NHS England and the Department of Health are still finalising to underpin the future arrangements, in partnership with a range of CCGs who are already moving through procurements using the draft ACO contract.

Even temporarily moving away from their current GMS/PMS arrangements can be a leap for practices, even though they can reactivate these contracts. This explains why in the early procurements the partially integrated model is likely to be the most popular form of ACO. Under this model all GMS/PMS contracts remain as they are. GPs remain independent but practices enter an integration agreement with an ACO provider. The agreement should address issues of integration around estates, the workforce and referral patterns so that everyone is working to the same model.

The event underlined the importance of setting out the specific actions each party is taking in the integration agreement. Otherwise, speakers warned, you may risk ending up with a slightly embellished community services contract. They also emphasised the importance of primary care to the successful delivery of the model.

Several areas are also trialling the virtual model where integration is encouraged through an alliance agreement. Robert McGough, a partner at law firm Hill Dickinson, suggested that with some providers only signing up to quite “loose” arrangements it will take some time to achieve significant integration and there will be a spectrum of models.

“The virtual or partially integrated ACO will not deliver core GP contract services so you will have to figure out how you integrate practices and change how they work. Enhanced services may well be within the scope of the wider ACO contract so that may be a way of incentivising GP involvement.”

McGough said “I’m not aware of anyone using the fully integrated model currently. Most are looking at the virtual model to test it out and perhaps use this as a staging post. GP collaboration is a fundamental issue but GMS and PMS contracts can be like rocks in the sand for integration. GPs only four to five years away from retirement may be questioning why they would take such a risk.

“It will theoretically be possible for GPs to reactivate their GMS or PMS contract if the ACO or MCP doesn’t work out. This option is proposed to be available at regular intervals throughout the ACO contract’s duration. However, the lack of certainty around the list in the context of the novelty of some of these arrangements explains why many practices are not initially opting for the fully or even partially integrated models.”

McGough also suggested that commissioners can still have influence the new commissioning rules, saying: “There is an appetite at NHS England and the Department of Health for listening to the case for regulatory change based around the lessons coming from the vanguards but that is a narrow window.”

[related articles:]

NHS England’s proposed contractual approaches for accountable care models

Commissioners must drive but leave providers to steer new care models

Accountable care organisations need support to get GPs’ pay right

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