Whatever you call them, new care models all face similar tough challenges. So how likely are they to succeed?
Graphics of the NHS used to be covered in risk pyramids. Now it’s multicoloured dartboards depicting local populations and their scaled-up GP providers, linked to an array of community and social care services, voluntary organisations, pharmacists and more.
In new care model language, these are multispecialty community providers (MCPs), covering more than 100,000 patients. The National Association of Primary Care’s model, which shares many features of the MCP, is called the primary care home – covering populations of 30,000 to 50,000. In South London, they are ‘local care networks’ – larger than PCHs (at around 75,000 patients) but smaller than MCPs.
Whatever their name and size, these new organisations have similar underlying approaches. They are linked to defined patient populations and combine preventive care and population health management with more traditional diagnosis and treatment. They seek to integrate the primary, community and secondary health workforce. And where this is a local priority, with the social care workforce too.
Together, the idea is to align clinical goals and financial incentives through novel payment systems. Overall, they aim to improve health outcomes and manage use of health and social care resources.
Different names, same challenges?
All of the new models – MCPs, PCHs, local care networks – face similar challenges:
- forming new working relationships between GPs and other professionals;
- linking data to understand need, support delivery and monitor progress;
- developing the workforce to work in new ways;
- developing budgets, financial flows and other incentives that stimulate different teams and organisations to pursue common goals;
- developing governance and contracting arrangements that support new ways of working without creating burdensome bureaucracy;
- engaging patients in the design and development of the new organisation.
Given these challenges, how likely is it that emerging care models will deliver what is expected of them in ambitious sustainability and transformation plans? A Nuffield Trust research team has studied large-scale general practice and multiprofessional provider groups for several years, and identified various factors that help and hinder progress.
Most recently, our evaluation of 13 PCH “rapid test sites” explored how sites are monitoring their progress and looked in detail at how three sites implemented their PCH vision.
The rapid test sites have risen to the challenge of personalised care and population health, developing an array of new services tailored to the needs of different population groups. Examples include community frailty services and innovative diabetic care.
The concept of the PCH – focused on population health and on building workforce skills and capacity – has energised local leaders and triggered new collaborations and better communications. Early wins include peer support for struggling GP practices that may otherwise have closed, and stronger links between community services, pharmacists, GPs and others.
But it is not all plain sailing. While some PCHs benefited from support and resources from their clinical commissioning group, others with vision, ambition and energy could not engage their CCG and struggled to make progress with some projects.
‘Energy and entrepreneurism in GP groups can be harnessed when links with the local CCG are strong’
These findings are consistent with some of our previous case studies – and with early findings from some vanguard sites – showing how energy and entrepreneurism in GP groups can be harnessed and woven into local service development plans when the context is supportive and links with the local CCG are strong. Equally, they can be stifled and delayed if CCG relations are poor – driving member practices to focus their entrepreneurial energy elsewhere.
Form or function?
Another challenge inherent in transforming primary care is whether to start with structure or function. Is it better to focus on a particular service or care group and use it as the vehicle through which to realign organisations, budgets and governance arrangements? Or have the early focus on structure and the contracting agreements needed to bring together GPs, community clinicians and others into a single entity or organisation?
In practice, both approaches need to run in parallel with neither running too far ahead of the other. A form of plate spinning that is hard to achieve but is evident in our previous case studies on medical groups with budgets.
Finally, while vanguard MCP sites and some of the PCHs are considering holding an MCP contract, experience to date suggests that board members remain cautious about accepting financial risk, and none have yet signed off a contract with the potential for risk and gain sharing.
Whichever approach is taken, experience tells us that sites will need to put in place significant management support and data collection and analytic capacity if they are to make rapid progress.
These are challenging times all around, with hard-pressed GPs and cash-strapped providers struggling to keep going with the day job, let alone innovate and develop new services. For those that manage to achieve this difficult balance, our various studies suggest the rewards come in the form of service innovation, enhanced professional satisfaction and more sustainable services in the long term.
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Successful new care models will need significant management support