Tracking everything that’s new in care models and progress of the Five Year Forward View. By integration reporter David Williams.
The week in new care models
- GPs annoyed at moves to set up a multispecialty community provider have broken cover. In a letter seen by HSJ Wakefield Local Medical Committee accused Wakefield Clinical Commissioning Group of having made “inadequate consultation” with GPs over plans to move to a “virtual MCP” for West Wakefield in 2017-18, before progressing to an integrated model. The letter said GPs would not “move forward” with the MCP plans without assurances that “there would be no progress from the original virtual model without consultation with and agreement from each individual GP in Wakefield”; and that core and non-core contracts would be protected. As I keep saying: 1) you have to keep GPs onside 2) there is no great appetite among GPs to give up their GMS contracts.
- Integration fans (myself included) have been watching with some interest the tentative moves in Salford, Oxfordshire and elsewhere towards bringing together provision of acute care and social care. But in a recent HSJ interview Simon Stevens has squashed the idea that these early schemes should be replicated and rolled out everywhere. “I very strongly think it would be a mistake to try and mandate one single solution across England”, he said. It has been rumoured that these tie-ups were attracting attention in central government. Either way, that is an unambiguous message to policymakers.
- During the interview Mr Stevens made a couple of references to the Frimley Health sustainability and transformation plan, as an example of one STP that was likely to progress to a fully integrated system. A couple of months ago we reported how Frimley was planning to expand its PACS across a wider population, into Berkshire. The final STP doesn’t quite go that far – presumably they haven’t quite agreed it with the GPs – but it does include an encouraging amount of detail about the way primary care is going to be scaled up across the patch.
- One new care models development to watch next year: national leaders clearly believe much outpatient activity is expensive and unnecessarily time consuming in terms of waiting times and consultant hours. In one bit of the Stevens interview we didn’t use, the NHS England chief lauded the changes to the diabetes pathway pioneered by Partha Kar in Portsmouth. Partha is Portsmouth’s clinical director for diabetes, and associate national clinical director for diabetes at NHS England, as well as being a prolific blogger and Twitterer. The Portsmouth “Super 6” model has been around for over five years now and is becoming a model of how cut hospital admissions by improving diabetes management in primary care.
Half a loaf is better than no bread at all
Simon Stevens has signalled a subtle but important shift in how new care models will be developed.
In his interview with me and Dave West last week the NHS England chief said he believed there was a huge appetite for scaling up general practice along the lines of “primary care home”, and that he would invest in and support the model next year.
He had much more to say about this than multispecialty community providers, and suggested that primary care home is where the “action” was likely to be over the next 12 months, while few areas would establish full blown MCPs any time soon.
So have national leaders given up on MCPs - and does this mean they are reining in their ambitions for scaled up primary care?
No – but they are being pragmatic and the emphasis is now shifting towards initiatives that will pay off quickly in many areas, rather than in a few places over several years. And, they are responding to signals from grassroots general practice, which is not overwhelmingly enthusiastic about the full blown MCP model in many areas, and in some cases is suspicious of it.
Although primary care home does not go as far as the MCP model, it is entirely compatible with it. In some circumstances primary care home could pave the way for an MCP or a PACS.
The particulars of primary care home will probably be familiar to anyone who has been thumbing through the primary care section of a sustainability and transformation plan. Not many STPs say “we’re going to do an MCP on X geography for a population of 250,000”. Several talk in vague terms about setting up an accountable care organisation. But many areas have plans to foster collaboration between GPs, setting up “hubs” serving a population of 30,000-50,000, providing an extended range of services via a more diverse workforce. The idea is that at that scale, primary care can provide a single point of access for all the services most people with long term conditions need.
These hubs, on that population footprint, are the building blocks of both MCPs and PACS. It’s just that MCPs and PACS do other stuff too, and wrap organisational and contracting structures around them.
What primary care home does not necessarily involve is new organisational forms, clever new contracts or partnerships with other organisations whom GPs don’t really trust. It can be achieved using existing practices, and GPs can continue to run the business. Although the model has been sponsored by NHS England in the form of a modest amount of transformation funding, it was worked up by the National Association of Primary Care. What all that adds up to is GP ownership: primary care home has the aura of being GPs’ own model, rather than something foisted upon them; GPs would continue to own their businesses; and GPs get to lead the future model.
Put another way: the barriers to setting up an MCP or PACS (contracting, organisational form, undeveloped relationships between various parties) don’t apply to primary care home. That means the model can be set up relatively quickly - if there is as much hunger for it among GPs as Simon Stevens thinks there is.
It is tempting to breathe a sigh of relief that primary care home doesn’t involve messing about with elaborate joint venture structures, assuring new organisations, innovative (a euphemism for untried and risky) contracts, and the dreaded public procurements. But only a masochist would get involved in any of those things if they didn’t offer an attractive prize: a simplified provider sector, the full integration of primary, community and acute care, long term contracts with fewer perverse incentives, and a structure that enforces a focus on population health.
Simon Stevens has recognised that this vision, which forms the core of the Five Year Forward View, is still a long way off in most places. The decision to emphasise and invest in primary care home next year is an acknowledgement that the whole NHS needs improved primary care as soon as possible. It is better to take a few important steps in the right direction today than wait – possibly forever – for everyone to take a giant leap.