Manchester puts general practice at the heart of devolution plan

18 October 2017

With the government trumpeting Greater Manchester as its devolution flagship the development of a localised form of accountable care in the city region will be watched particularly carefully.

The Greater Manchester Health and Social Care Partnership now controls the £6 billion health and social care budget devolved from Whitehall.

Eventually ten local care organisations (LCOs) will deliver the transformation in ten localities set out in the Greater Manchester strategy. The central and largest part of the GM region – the city of Manchester itself – is the most advanced in procuring the new arrangements and a few other localities are on that same journey.

The Manchester procurement is in the due diligence phase with the sole provider that sought the £2 billion contract. That provider, the Manchester Provider Board, has four owners or members: Manchester City Council, the acute and mental health foundation trusts and the Manchester Primary Care Partnership (the umbrella group of three GP federations).

GP Tracey Vell is both chief executive of Manchester Local Medical Committee and associate lead of the Greater Manchester Health and Social Care Partnership.

Addressing a recent PCC event on new care models for general practice, she said: “General practice is driving new models of care and local care organisations. Primary care is now increasingly viewed as the core component of an integrated, community based care system rather than a separate standalone entity.”

Acknowledging it can be difficult to get a single voice for general practice, Vell said that initial efforts to persuade the seven LMCs to represent that voice was not successful. Instead, new governance arrangements were set up and general practice has a voice in the evolving arrangements through a GP advisory group made up of the LMCs and GP federations.

Vell said: “We need to decide how we as GPs speak with one voice. If you want to go further through this changing landscape you need that single voice.”

The LCOs will bring together community health services, social care, acute and mental health providers and the third sector. They will coordinate the activity of several population hubs, each with the currently fashionable population range of 30,000-50,000. Nine of the ten LCOs will be responsible for five or six hubs covering around 200,000 people.

The exception, the first in central Manchester with its larger population of 625,000, will oversee around 12 hubs.

“We have moved practices into working with those population sizes but we are just asking them to work together – not to merge. We think that having that group of five or six practices is a game-changer as it incentivises shared working – such as the care of care home residents and urgent access arrangements for each other’s patients.”

She continued: “The LCO agreements have very wide outcomes rather than service specifications because we want to incentivise prevention. We have never been able to deliver prevention before because it did not provide a return on investment in the two year commissioning cycle but we need to do it if we are going to radically change healthcare.”

LCOs will be expected to:

  • Support management of conditions at home and in the community – including through delivering some acute services out-of-hospital and providing more accessible urgent care in the community
  • Work with all relevant public sector partners to improve population health – including economic wellbeing and housing
  • Support people and their communities to take more control over their health by drawing on the strengths and services of the voluntary sector
  • Take full responsibility for the management of the health and wellbeing of their population – including by risk stratification and expanded multi-disciplinary teams.

“We are trying to enable the right thing to happen to the patient in the right setting so it does not fall back on the GP,” she said.

As elsewhere, the gap between legislation and evolving policy and innovation has forced some creative thinking around the shape of the delivery vehicle in central Manchester. Vell says that the preferred ownership option for the new multispecialty community provider – a community interest company – would leave it liable for VAT.

With GPs understandably reluctant – indeed unwilling – to work directly for an acute trust, the interim solution sees the acute trust nominally holding the contract.

Vell says: “we’ve made clear that the contract has to run straight down to the LCO board for decisions on governance, risk etc.”

Another request is a higher capitation rate for practices, a red line being that no GP practice loses money.

Vell said: “Under the partial integrated contract practices will put forward their enhanced services funding into the new LCO ringfenced and then delivered back to practices for different outcomes by the GP federation.”

Central Manchester

Risk stratification and the formation of a high impact primary care team are central to efforts to transform health and social care for Manchester city’s 625,000 people.

The local health and care partners have identified the 2% of the population – 12,492 people – most at risk of emergency hospital admission. That includes people with several long term conditions, frail older people and around 600 people with “complex lifestyles” – such as homelessness.

The high impact primary care team will include social workers, community nurses, a pharmacist, primary care nurse practitioners, mental wellbeing support workers, GPs, care of the elderly consultants and third sector “community connectors”.

They will offer:

  • 30 minute appointments
  • Proactive care with regular planned patient contact
  • Multi-disciplinary teams with access to shared record
  • Timely and inclusive care reviews
  • Shared care across care settings – including the home, care home and hospital
  • Access to specialist advice, opinion and diagnostics.

Meanwhile, 12 integrated neighbourhood teams will focus particularly on the 12% of the population with the next highest level of risk of admission to hospital. Bringing together adult social care services, community health, mental health, some children’s services, reablement and homecare services, these teams will include key workers and provide enhanced triage.

A prevention service with a large voluntary sector and public health component will focus on the 40% of the city’s population that is considered next most at risk of hospital admission.

People will be able to step up or step down between the three levels following a single, integrated strengths-based assessment.

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