Multispecialty community providers (or MCPs) were one of the new care models (or NCMs) identified in NHS England’s Five Year Forward View, seen as providing a new way of breaking down the traditional divide between primary care, community services and hospitals.
Based on the registered lists of general practice, MCPs ideally work at scale as super-practices or through networks or federations of GP practices. Such practices could, through an MCP, incorporate community staff or provide a single point of access to multi-agency services.
NHS England recently published its long awaited framework on what MCPs might look like in practice, identifying three broad types – ‘virtual’, ‘partially-integrated’ and ‘fully-integrated’ This article focuses on the issues and challenges that an MCP might face in utilising any such emerging care model, and compares each of the models.
Steps towards integration
NHS England is currently working with six MCP trial systems to develop draft contracts to support the partially and fully-integrated models, which should hopefully be available by the end of September 2016.
The first MCP type, the virtual model, is a pragmatic step towards integration as individual providers and their commissioners are bound together by an alliance agreement. This overlays but does not replace existing commissioning contracts. Maintaining the status quo regarding the delivery of services and the identify of providers means that the impact of issues around VAT, pensions, clinical negligence and regulatory requirements such as CQC inspection and registration, for example, are likely to be minimal.
Using this option is likely to be attractive to GP practices who wish to engage with an MCP but do not want to give up the certainty and security of their General Medical Services (GMS) or Personal Medical Services (PMS) contracts. GP engagement is essential to the success of an MCP model, and many GPs would welcome the opportunity to add new services to their practices, but they will want to know that they can go back to what they had previously if the new model doesn’t work out.
An alliance agreement is likely to require a change in mindset as all participants will be obliged to act in the best interests of the MCP rather than for themselves.
A virtual MCP could be seen as the weakest model in terms of creating and managing integrated provision and using resources flexibly and efficiently. This type is also limited in scope as it does not benefit from a whole population budget – a single budget paid to the MCP which will cover the full range of services for a population living in its area.
Under the partially-integrated MCP model, a new contract will be awarded to a single provider – either a new corporate entity or an existing provider acting as lead provider. This will allow greater scope for integrating more services than the virtual MCP, which is constrained by an alliance agreement.
The new partially-integrated contract will include all services except primary medical services, supported by an additional integration/collaboration agreement. This may appeal to GPs who do not want to give up their existing GMS or PMS contracts and they may be more willing to engage with the MCP on this basis. However, the need for an integration/collaboration agreement complicates rather than simplifies existing arrangements and there may be issues for partially-integrated MCPs around pensions, clinical negligence, VAT and regulation.
The main challenge arising from the use of the partially-integrated MCP model, it appears from NHS England’s MCP emerging care model and contract framework, is that this model will not include simplified payment arrangements or the longer contract duration of the fully-integrated MCP contract. Similarly to the virtual model, it also doesn’t benefit from a whole population budget.
A transformational model
The fully integrated MCP model is the most transformational, supported by a contract which includes all primary medical, community, mental health and social care services, and will be long-term (10-15 years) but with a break point after 2-3 years. It will also be adaptable, as it will allow additional services to be added during the life of the contract after the initial break point.
It will simplify payments by having a whole population budget, replacing the Commissioning for Quality and Innovation (CQUINs) payments and the quality and outcomes framework (QOF) schemes with an MCP performance payment which includes a gain/risk share arrangement with local providers.
It does however require the creation of a single legal entity to hold a fully-integrated MCP contract.
The main downside of this model is that it is dependent upon GPs giving up their current GMS or PMS contracts. It is unclear how willing they will be to do this without a formal amendment to regulations, where commissioners agree with GP practices to allow for a return to a GMS or PMS contract at a defined point in the future.
The MCP model which is adopted will depend on the appetite for change and the degree to which commissioners and providers are in a position to make changes now. Key to this will be the willingness of GPs to engage with MCPs. It seems unlikely that GPs will determine this until they have a full picture of what they are signing up to and whether they will have a right of return if they do.
This article was first published in Laing’s Health Market News, October 2016.