The first year of Circle’s contract in Bedford - the country’s first whole population MSK care contract - provides a useful prescription: policy clarity on referrals, data sharing and registration are all essential, writes Will Smith

Last year, Circle started a contract in Bedfordshire managing musculoskeletal care.

‘We believe we are starting to show the real benefits of integration’

This is not quite the same as the vanguard sites or health and social care integration. But as the first whole population MSK contract in the country, it is a new model and it is integrating community, primary and secondary services.

Our experience in Bedfordshire – good and bad – suggests several lessons for future reforms.  

Lessons learned

First, structure matters. New models are brilliant for redesigning services around patients but reflecting that in governance and legal form takes a lot of thought – probably more than we appreciated.

We tried to register as a new form of care organisation, for example. This was the obvious route, given we wanted to create a new coordinating body with an explicit mandate for change.

Will Smith

Will Smith

This meant, however, that the Care Quality Commission registration team was unsure whether to treat us as a provider or not. In the end, we registered as a sub-clinic of Circle’s hospitals. But the process took two months - a significant delay in the context of a busy first year.

We also found national data law prevented us gaining the accreditation needed to access patient information. Again, we found a solution: using anonymised patient records translated into our system - but there could surely be a swift, legal way for prime contractors to have the same data as commissioners. 

‘Governance and legal form take a lot of thought - more than we appreciated’

These issues were compounded by the rules around referrals

We now believe we are starting to show the real benefits of integration. We give specialist MSK triage to 100 per cent of patients within 24 hours of GP referral. Half of those referrals are electronic, up from 7 per cent before.

We change roughly one in five GP decisions – meaning the same proportion of patients were previously sent to the wrong clinician – and the proportion of patients going on to secondary care is down 24 per cent. We have reduced average physio and diagnostic wait times, while a host of outcome measures can now be monitored. All of this for a flat fee, instead of ever rising spending.

These changes rely on MSK referrals coming through our triage centres. Our challenges with Bedford Hospital Trust here, and its argument that our system would undermine emergency services, are well known.

Both sides now recognise that this is primarily an issue around national trauma tariffs – not a fundamental objection to a prime contractor model – and the trust, Circle and commissioners are now working together to both protect trauma services, and run our model.

Policy difficulties

Yet even with that progress, policy makes it difficult to bring patients into an integrated system.

Our commissioners developed a “prior approval scheme”, for example. This asks any provider that receives a patient outside our system to send them back to us for triage.

But providers pointed out that the “who pays?” rules permit them to seek payment for patients treated, and argued that if a patient had chosen them, it would be illegal to reject their choice.  

In our view this missed the fact that in our system, after triage patients are offered choice over who treats them. That way, we harness the benefits of both competition and integration – and in fact, by making choice explicit (98 per cent of those requiring secondary care are verbally offered choice in a phone call), we think competition is a more powerful tool for improvement than perhaps seen elsewhere.

Still, providers will rationally seek to protect income – and the rules are unclear.

‘Policy clarity on referrals, data sharing and registration are all essential’

Even then, a prior approval scheme treats the symptom. The root cause is GP referrals bypassing our system. But commissioners currently have limited influence over GP referrals: despite having created a service specifically to integrate MSK services that is reliant on GP referrals and explicitly offers choice, they can’t simply enforce its use.

The prior approval scheme is now in place, but only after a year in the contract. Until guidance is clarified, it is easy to see similar delays occurring wherever a new model requires a single patient point of access.

Despite these challenges, we now see 90 per cent of MSK patients, up from around 40 per cent in the first months of the contract. How have we got so far?

The short answer is: persuasion. And this is perhaps the biggest lesson of all. An appeal to the moral high ground is surprisingly effective.

We continually emphasise that we are creating a system that is more joined up, cheaper for taxpayers, better for patients, and means clinicians see the right patients. Moral and political support from local and national bodies is essential to getting that across.

Our first year in Bedford provides, we believe, a useful policy prescription: policy clarity on referrals, data sharing and registration are all essential. More than anything, though, it shows we need a culture that encourages the innovators and reformers.

Will Smith is general manager of MSK for Circle