Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by mental health correspondent Rebecca Thomas. 

This month we had the return of the integrated care provider contract.

In theory, this should be a big deal for NHS policy, but with just one area likely to be using the contract in the near future, the relevance of it is somewhat hypothetical.

Regardless, there are a few things worthy of note in the most recent iteration.

First is the omission of a previous rule that prevented an integrated care provider from holding more than one ICP contract at a time. This omission means, in theory, that a provider could hold an ICP contract across two sustainability and transformation partnerships, if it had GP partners in both areas.

In reality, this is unlikely to happen now the contract cannot be handed to a private provider.

The integration specific requirements for fledgling ICPs are also interesting.

Any provider, for example, will have to have information systems and data sharing agreements that allow it to understand and analyse the health needs of its population, and identify, for instance, which members of its population are at risk of developing certain diseases.

The providers must also “use all reasonable endeavours” to offer patients alternatives to face-to-face contact, creating opportunities for the likes of Babylon.

Some areas are already on their way to achieving both these requirements, but having it within a contract would be an additional push.

Purchaser/provider split

The big question on everyone’s lips when NHS England first revealed its ambitions for this contract was whether it would end the purchaser/provider split.

The answer appears to be ‘not really’, as there’s nothing within the final version of the contract which suggests commissioners will be able to completely transfer their statutory roles.

For example, before subcontracting a service, an ICP would still need to gain commissioner permission.

Although the contract will give providers a greater say in commissioning decisions and budgeting, those hoping the final version would spell the undoing of the Lansley reforms will be disappointed.

Financial risk

If they do get off the ground, ICPs will be handed big budget multiyear contracts.

The contract size will vary depending on how many GP practices agree to include their contracts and the extent to which social care is involved.

The details around how the non-core GP elements of the contract should be costed are vague and non-prescriptive. The baseline calculations are a mixture of historical activity, demographic modelling, benchmarking activity trends etc, but will need to allow for future flexibility.

Those thinking about either commissioning or providing will want to weigh up where the financial risk sits.

Clinical commissioning groups will bear the risk of changes in population size and demographic, although this is, in theory, addressed by their yearly allocations.

The ICP, on the other hand, will bear the risk of:

  • activity changing – patients using services more or less frequently;
  • variation in patient usage patterns;
  • efficiency savings not realised; and
  • changes which impact the quality of care.

Is this contract required?

The likelihood of this contract becoming a mainstream vehicle for integrated care systems in the near future is low. While some areas are now starting to look into its use – Barking, for example – Dudley CCG is the only commissioner to have started a procurement process to use this contract.

As a reminder, these plans would effectively split the Dudley Group FT in two, with a new trust being formed around its community division. This new legal entity would then hold the ICP contract, allowing GPs to sit on the board.

However, the CCG’s chosen vehicle is still mired in regulatory haze, while providers are still working through the budget details, so it’s not clear when the ICP will come to fruition.

You could also question whether the new contract is needed.

Some would argue the ends of the ICP contract can be met through other means, such as the primary care network contracts, for example.

There are several areas where the ICP contract mirrors what PCNs are designed for, such as incorporating multidisciplinary primary and community care services and social prescribing.

Would a partially integrated ICP, in which GP practices still hold their own contracts, be any different to an NHS trust alongside a group of PCNs?

Since both PCN and ICP contracts are untested, we’re unable to answer this question with any certainty.