The biggest challenge for the NHS in the decade is how to improve care, while making savings. Prime provider musculoskeletal contracts is one answer but ill founded criticisms of the approach undermine innovation, argues Nick Boyle

Prime provider contracts for musculoskeletal services are attracting a lot of attention and a lot of controversy.

But the criticism is often ill founded and risks undermining an innovative way to improve services.

Nick Boyle

Circle has been running the first prime provider contract for MSK services in Bedford since April.

We are responsible for bringing previously disparate services into a single triage point and a single patient hub, subcontracting with all the other providers, and offering patients choice over which provider they go to.

What it means

For the patient, that means a much smoother, quicker journey, with no more bouncing around from GP to physio to consultant, with paperwork and delays at every stage.

For doctors, consultants, therapists and physios, it means more patients turning up to see the right clinician first time round, and more consistent use of best practice in clinical pathways.

For the local NHS it means, quite simply, saving a lot of money. For a commissioner, the contract is a smart risk transfer to the private sector.

Instead of an ever increasing demand, they can cap spending and ask the prime provider to deliver services within that sum.

‘The prime provider takes the hit if the service fails’

That means it is up to us to make the risk calculation about unexpected demand; to project how quickly we can integrate other providers and capture referrals; or to make sure responsibility for waiting time breaches, care issues or legal liabilities are all clearly allocated.

We negotiate these things with the commissioners, but the burden is very clearly on us to work out these nuts and bolts. Some might call this a crude or blunt way for clinical commissioning groups to operate - we would call it neat.

In short, the model aims to take a failing system with enormous inertia that doesn’t work for patients or the local NHS, and changes it to one that offers better, more integrated care, choice and savings, all with the prime provider taking the hit if we fail.

Not a bad combination.

Prime provider contracts don’t create challenges

Some critics say this all beside the point, because if elective referrals drop some hospitals’ trauma services might be undermined.

This is understandable, but completely misguided.

If elective tariffs really do cross-subsidise trauma services, that is an issue for better tariff pricing and more equal treatment, not for supporting an existing system.

This also tends to be a concern voiced by smallish district general hospitals. But the relative instability of their finances is driven by much broader trends:

  • lack of specialised services income;
  • acute pressures;
  • vagaries of geography and demography; and
  • sometimes inefficiency.

Prime provider contracts only highlight existing challenges for DGHs. They do not create any new ones.

Improve and patients will come

If any given hospital has its income reduced by the prime provider contract, the simple answer is to improve.

So far in Bedfordshire patients have shown that they value clinical excellence as a minimum, and that choice between providers is also led by practical considerations: how long they have to wait for an operation; how far they have to travel; and how much they will be changed to park.

‘If a hospital can offer a good service, they will see increased patient numbers’

If a hospital can offer a good service, they will see increased patient numbers. This is a perfectly sensible arrangement that encourages all providers to do the right thing, rather than rely on guaranteed volumes, regardless of quality.

And it would also be wrong to look at one hospital in isolation.

In Bedfordshire, Bedford Hospital Trust tends to attract the most attention, but it isn’t the only nearby NHS hospital.

Luton and Dunstable Hospital’s referrals have remained largely consistent, partly because they have partnered with us, and partly because patients have chosen to go there. They seem to see the prime provider as an opportunity to re-think services and collaborate better with other providers.

Making the case for change

These contracts are new and as more emerge, increasingly we expect to partner with large trusts in any given area.

Indeed, Bedford actually turned down our offer to submit a joint bid – but that’s another story. The point is, no trust with a sensible grasp of their services and a desire to face the future need fear MSK contracts.

But overriding any of these objections is the big, long term picture for the NHS.

‘The challenge in the NHS is how to both improve care while making savings’

In the coming years, we will face this situation again and again: when a new system, trying to both improve services and make them sustainable, faces opposition simply because it disrupts how one part of the system has worked for years.

We need to understand these concerns. We need to work with them.

But it is in no one’s interest to let them undermine the case for change. The central challenge everyone in the NHS faces for the next decade is how to both improve care while making savings.

Prime provider MSK contracts are one answer. Defending the status quo for its own sake is not.

Nick Boyle is a consultant general surgeon for the Circle Partnership