The Commissioner: New commissioners – a lead provider

This occasional series hears from people whose roles or organisations are new or undergoing a lot of change – this week Glen Burley, South Warwickshire Foundation Trust and Wye Valley Trust chief executive. South Warwickshire has become a “lead provider” for community services and sees itself becoming “an integrated care organisation”, taking on commissioning roles and exploring financial risk sharing with GPs.

Becoming a lead provider

Glen Burley: “Coventry and Warwickshire clinical commissioning groups went through a procurement last year and used the ‘most capable’ provider route. [South Warwickshire Foundation Trust] worked with Coventry and Warwickshire Partnership Trust with GPs and GP federations and key local stakeholders including other local hospitals, hospices, local authorities and the voluntary sector.

“South Warwickshire FT was appointed lead provider in south Warwickshire, Rugby and north Warwickshire and CWPT was appointed as lead in Coventry.

“We have technically become, albeit in a small way, an integrated care organisation. The other important change that the contract brings is the ‘lead provider’ role. Through this we are required to work with other providers such as CWPT and the local hospices to commission elements of the contract delivered by their teams.

“This brings with it the requirement for us to develop new skillsets and we are doing so in partnership with local CCGs.

“It is a different type of contract. Each year a bigger element of the payment will be linked to patient outcomes that seek to reduce demand on the acute sector. It is capitated payment — we won’t count activity. In south Warwickshire the contract also works alongside and complements our contract for urgent care services.”

Financial gain share with GPs

“As the community services lead provider we are working with GPs and GP federations. I see no reason why, as lead provider, we can’t create a gain share arrangement with GPs.

“We have started some work to look at a model. My thinking is we make it an outcomes based arrangement. If they don’t deliver a reduction in secondary care, they don’t get all or some of the incentive. There are already additional payments to GPs for various things like [the quality and outcomes framework], which could be used to further incentivise the right outcomes. We are having discussions with the CCGs on the nature of the contract but it is founded on the existing, standard NHS terms.

“Alongside this, we have started to put more capacity into out of hospital care. One example is for discharge to assess, including commissioning GPs to provide support in care homes.

“We want to offer more alternatives to admission and we are doing new prevention work in collaboration with GPs with over-75s.”

Foundation trust as integrated provider

“Why use the FT model as opposed to creating some new organisational form? Joint ventures bring tax issues and other complexities. Other alternative organisational models are likely to be less publicly accountable than FTs.

“FTs have the ethos of social enterprises coupled with the strong governance of the public sector, and a governor model that engages the public, staff and local stakeholders – so why reinvent them?

“FT governance rules require that public governors hold the majority on the council of governors. FTs then have a degree of flexibility about stakeholder governors. For FTs providing integrated care it would make absolute sense to have a local medical committee representative, which we have but they are not a requirement, as well as local authority reps.

“Creating a new organisation [to be the integrated care provider] or trying to make GPs become employees comes over as threatening, a threat to GPs’ traditional contract. I don’t really think you need to do that to make progress.

“Most primary care businesses in this patch are reasonably stable and we don’t want to provide primary care services when they are better placed to do so.”

Why is the FT trusted?

“Are we wolves in sheep’s clothing? There is still a view FTs have a till at the front door of the hospital and want to bill for all work. We’ve tried to show we are not doing that and that we are more system focused.

“It’s taken a long time to get to that place. There is a longstanding relationship between both trusts and GPs in my patch and there are reasonably collaborative GPs.

“GPs have a degree of confidence in the trust as we’ve worked together in some parts of the county before.

“We have spent a lot of time in the room with GPs and have been talking a lot about what we are planning to deliver differently. We’ve spent a lot of time just coming up with these plans.

“The trust’s community division has a GP associate medical director, so there is a GP at our management board table every time we meet.

“The CCGs have taken a bit of the steer from above about some of the operational commissioning being more with providers, about moving to accountable care arrangements. This represents real progress as a few years ago they were thinking about competitive procurement.”

‘Super block contract’ in Wye Valley

“At Hereford [where Wye Valley Trust is based] we have put in place what I call a ‘super block contract’ including all non-elective and elective activity. As a consequence, there is absolutely no incentive for us to do activity we don’t need to do.

“There has been an elective waiting times problem at Hereford for some time and as a consequence, a transactional approach developed. We have now said let’s put that to one side and have a different relationship.

“We have stuck to it so far. We are trying to look at actually managing demand. The activity is already paid for, although there is a potential clawback if we don’t deliver on referral to treatment.

“For South Warwickshire we have a block contract for community services with a ceiling on urgent care activity in hospital.

“It is easier for me with these trusts to take a block contract than for other acutes because they are integrated hospital community providers and are better placed to influence system demand. Otherwise, trusts that are solely acute providers can be left with stranded costs.”