New care models: now available in GP-friendly packages

24 January 2017

By Julian Patterson

There are a number of reasons for general practice to change – it is often small and called inefficient, with wide variations in quality from one practice to the next. Workforce shortages and workload pressures, too, argue for working at scale.

There are also things GPs and patients are desperate not to change – general practice is local, personal and often delivers exceptional care as well as excellent value for money for taxpayers.  

The scaled up version of general practice imagined by policymakers makes complete sense: organisations big enough to cope with changes in demand, able to expand the range of services they provide, able to benefit from economies of scale, and able to make more creative use of the wider primary care clinical workforce to free GP time and add value for patients.

However logical or inevitable big general practice may appear, practices are left with a number of questions:

  • How do we grow big without losing the benefits of being small?
  • What are the longer term gains and what might we have to give up for them?
  • How do we retain a voice in the new bigger enterprise?
  • How practical is it to share patients and workforce?
  • How do we bring patients along with us?
  • What about governance – who is ultimately responsible for care when patient lists are shared?

And the biggest question of all: how do we find time to make the changes we need to make when we’ve never been busier?

A set menu

The new care models described by the Five Year Forward View, particularly the multispecialty community provider (MCP) variant generally considered the most compatible with general practice were intended both to address the big demographic, capacity and financial challenges faced by the NHS, but also to nudge general practice towards the scaled up working seen as necessary for its own long-term survival.

That vision has not been shared by all GPs – either because they suspected the motives of policymakers, because they were unwilling or unable to work in bigger unit, because they did not accept that the traditional model needed to change, because they believed that more would be lost than gained in the process, or simply because they were too busy getting on with the day job.

As new care models took shape and hardened into organisational and contractual forms, they began to raise more fundamental questions about GPs’ employment status and what would become of the GP partnership, the basic organising principle of general practice for most of its history. 

The ideal version of an MCP involves GPs giving up their GMS “in perpetuity” contracts for time-limited contracts and pooling their patient lists to become servants of “populations”, a bigger and somehow more nebulous concept. NHS England has responded with compromises designed to make the contract more palatable – including a right to return to GMS, but this issue has undoubtedly slowed the transition to new care models.

Going with the grain

While the real or imagined threat to GPs’ job security may have played its part, it is just one of a number of negative factors affecting general practice including growing population, rising demand, pressure on hospitals and social care, a relatively shrinking workforce (a net increase of just 500 new GPs in the past five years) and falling income. The effect of these factors on morale can be seen in numerous surveys measuring GPs attitudes to their jobs, in the numbers retiring early or leaving the profession and in the struggle to recruit the 5000 additional GPs the NHS has been promised..

Announcing the GP Forward View last April, Simon Stevens explicitly acknowledged both the vital role of general practice in the NHS and that GP funding had fallen behind. The GP Forward View came with a promise to increase GP funding both in real terms and as a proportion of overall NHS spending, though the figures identified in official documents which show a rise in the primary care budget from £9.6bn in 2015/16 to £12bn by 2020/21 also include non-GP services. 

Stevens has also started to modify the new care models message. In December he was quoted in the HSJ as saying that the “primary care home” model “goes with the grain”.

Drawing a contrast with the larger scale experiments of the vanguard programme – MCPs aim at populations of around 100,000, PACSs at those of 250,000 or more – Stevens painted a picture of GP hubs serving populations of 30-50,000.

He said: “There’s a huge latent appetite for something like [primary care home] – not necessarily full blown integration between practices and super-partnerships, but something that is in the middle ground between individual practice sovereignty and complete pooling of assets and employment and the contract.”

He is clearly attempting to raise the pulse of the profession about general practice at scale while administering a calming dose of traditional general practice. While Stevens is certainly not saying that the new emphasis on a more gradual approach using smaller building blocks spells the end of more grandiose schemes, we can certainly sense NHS England’s foot coming off the gas.

Going “with the grain” means tapping into the existing relationships and natural alliances at locality level. It also means starting with something that is recognisably a scaled up version of today’s general practice. Primary care home is a much more GP friendly brand than the unwieldy terminology of MCP and PACS or the transatlantic jargon of accountable care organisations.

Last year’s model

The focus on the primary care home model also allows the issue about the contractual status of GPs to be parked – at least for now.

Or to put it in the carefully chosen words of an NHS England chief executive: “Thousands of practices are going to be involved in team working with other practices in a structured way. I don’t think thousands of practices will necessarily be in a full blown MCP contract over the next 36 months.”

One of the great ironies of the much-maligned reforms made by Andrew Lansley was that they failed to appeal to the group they were designed for. With CCGs (originally called GP-led commissioning groups) Lansley was trying to bring the strengths of list-based general practice to bear on the same set of problems that the Five Year Forward View would return to two years later.

The Stevens project is now equally focused on general practice but with a more conscious effort to convince general practice that its own salvation and the future sustainability of the NHS are intertwined.

The mixed results from the vanguard programme, the difficulty of evaluating the pilots and the growing number of voices warning that transformation is a long-term project – certainly longer than the three remaining years of the Five Year Forward View – will all have helped convince NHS England that lowering the centre of gravity of new care models in the direction of primary care makes sense.

There’s a pragmatic dimension to the story too. Funding for the vanguard programme has been cut back sharply as the dial has swung from transformation to sustainability. Funding primary care home sites and similar GP hubs means a lower outlay with a higher chance of success and a much better return on investment than bankrolling more vanguards.

They’re last year’s model. The primary care home is the one to watch in 2017.

Julian Patterson is Director of marketing and communications, PCC.

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