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Scaling up general practice

Scaling up general practice

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Commissioners need to start preparing practices for working as part of large-scale organisations, but it won’t happen without its challenges

Many clinical commissioning groups (CCGs) are keen to encourage general practice to work at scale, in organisations like federations or super-partnerships. The idea is that they will then be better placed to save money and sustain local practices, and deliver more services in community settings. Progress has been made to this goal – more than 73% of respondents in our recent survey of practices suggest they collaborate with others.1
Yet large-scale general practice organisations are developing at different speeds across the country. Most are still finding their feet; unsure of their aims and ambitions. A small number are forming multi-specialty community providers (MCPs) or joining primary and acute care systems (PACS). These are two new care models responsible for local whole-population budgets.
At present, NHS England estimates that MCPs and PACs provide care to about 8% of England’s registered population, but it has plans to extend national funding and support to ensure they cover one-quarter of the country’s population by 2017/18.
NHS England’s first guidance document on commissioning new care models, the MCP Contract Framework,2 was published in late July and described at a high level how commissioners would be responsible for local provider development, procurement and contract negotiation. As well as providing more detail on how these organisations will function, it also raised a number of challenges. Here, we advise on how commissioners can prepare large-scale general practice organisations for transformation – the first step in the process – and also outline some of these challenges.

Learning from progress already made
Each MCP will require a large-scale general practice provider as its foundation. Therefore, it’s important to start by looking at progress already made and what we can learn.
We recently conducted an evaluation of large-scale general practice using national surveys and an in-depth 15-month case study in four mature large-scale organisations.3 The surveys revealed that while most GP practices are part of a large-scale organisation, the majority have formed recently. It will take around two years for them to create an organisational plan, develop effective governance arrangements and start to deliver care in new ways. A challenging local history among GPs and the lack of a supportive relationship with local CCGs was cited by case studies as hindering their development.
Our case study sites also demonstrated that GP practices working at large scale were able to start initiatives to sustain and improve their core general practice services – developing the workforce, deploying technology and improving organisational efficiency. But this came at a cost – in terms of an exceptional commitment of time from highly motivated leaders. A ‘heroic’ model of leadership was often seen, and this may not be sustainable. It may be necessary for commissioners to get involved in developing leaders and encouraging distributed leadership.
Among the 73% of surveyed GPs who said that they were in a large-scale organisation, around 50% said that they were motivated to form because of the option to expand their service scope and deliver extended services. Our case study sites are excellent examples of services that were rated highly by patients and primary and secondary care staff who worked as a single team.
However, none of our case study sites had yet developed pathways across a whole specialty or held budgets to do so as specified in the MCP Framework document – so even mature organisations are in the foothills of transformation. Again, they told us about the importance of good relationships with commissioners, as well as hospital specialists, to be able to do this.

Five ways to make commissioning more effective and useful
While our surveys highlighted ways in which CCGs could help develop local providers into potential MCPs, our recent report Is Bigger Better? Lessons for large-scale general practice4 identified five major lessons for commissioners:

  • Help providers set clear goals: Most large-scale general practice organisations we surveyed had far too many goals. At a high level, three consistent and common goals observed were:

1) sustain and improve core GP services
2) deliver extended services
3) lead whole-system change as an MCP.
CCGs can play an important role in creating clarity and setting a direction. However, it will be important they take a realistic view on the capacity of large-scale organisations to take on extended roles, to develop specialist skills, and to set up new services – before becoming MCPs. It would be preferable to allow large-scale general practice organisations to develop at a pace that allows them to bid for, and establish new services without becoming overwhelmed before taking on MCP status.

  • Facilitate relationships between primary and secondary care providers: To extend services out of hospital requires sustainable CCG funding and good relationships with secondary care. Commissioners can help collaboration by facilitating joint training or by funding joint posts across primary and secondary care. Commissioners can also support new organisations to deliver extended services by funding pilots and helping to shape new pathways across specialties – with a goal to provide sustained funding through an MCP contract or otherwise.
  • Manage conflicts of interest: CCGs should tread carefully with conflicts of interest. Although new models create risks, CCGs need to avoid excluding GPs with an expert knowledge of a specific area of care from service redesign work because of potentially conflicting leadership roles. Recent research from the Nuffield Trust and King’s Fund highlights how CCGs still feel that they are not given enough autonomy to involve GPs effectively in decisions about the design of local services.5 NHS England is to publish guidance this year to clarify conflicts of interest, but for now suggests that CCG staff looking to move to MCPs divest themselves of commissioning.
  • Invite providers that work across CCGs to share knowledge: During our evaluation we heard that organisations working across multiple CCGs found it difficult to engage with CCG governing bodies. However, the leaders of these provider organisations were often entrepreneurial systems thinkers, and were privy to knowledge and experience that was beneficial to local service development. It is still unclear whether MCPs will be allowed to work across wider geographic areas, but in the meantime there may be opportunities to engage widely.
  • Keep patients and communities engaged: It is important that CCGs facilitate local debate between patients, the public and other stakeholders about how large-scale general practice organisations can contribute to population health improvement and to the local health economy.

Keeping patients engaged will be important, as we found little understanding among patients about how general practice was changing in our case study sites.

The unknown
Once large-scale general practice organisations are up and running, they may consider bidding for an MCP contract. NHS England’s MCP framework answers some questions about the form and function of MCPs but also raises a number of ambiguities and challenges.
With little room for more than one large provider in each local area, one of the most critical roles for commissioners will be to decide which of the large-scale organisations, MCPs or PACSs, can move services out of hospital and hold budgets as part of their local sustainability and transformation plans (STPs).
CCGs will need clarity on how to assess these new organisations and what to do if the organisation is underperforming or fails.
At present, large-scale general practice organisations operate with differing governance and geographic arrangements, according to their history and purpose.
It is not clear whether MCPs will be required to form out of practices in a single geographic area, or whether they could operate practices across the country like some larger corporate general practice providers. This will be important for CCGs to understand as they support provider development.
The move towards contracts of 10 to 15 years should give commissioners and providers the space to implement change.
It also poses challenges, despite the contract’s break clauses. Given the rapidly changing nature of the healthcare landscape and its finances, a 10-15 year contract may bind commissioners’ hands for longer than is desirable after the initial break period has passed.
CCGs are well aware that some of the new provider organisations they are creating could take over some responsibilities for service delivery. In some areas, commissioners and providers might be well placed to take these on and develop MCPs from large-scale general practice groups. Others, though, may not be in a position to do so. Service redesign, for example, requires joined-up records between provider sites, real-time data flows, business intelligence systems, and access to significant analytical capacity, as emphasised by NHS England in the framework. This is costly and time-consuming work that requires expertise that some areas do not have.
So moving services out of hospital may be a slow process and timescales and ambitions may have to be adjusted.
Understanding what responsibilities should be moved to new provider organisations is an important piece of the countrywide transformation process. There remains a role for an effective commissioner (or ‘payer’ as it is referred to internationally) to ensure providers are fulfilling their obligations.
Working out what this means for the size and scope of CCGs is an important, and as yet unclear, step in the implementation of MCPs. CCGs will need support and information if they are to continue to, in effect, rewrite and scale back their job descriptions.

References
1. Kumpunen S, Curry N, Edwards N et al. Collaboration in general practice: surveys of GPs and CCGs Nuffield Trust and the Royal College of General Practitioners, 2015 nuffieldtrust.org.uk/publications/collaboration-general-practice-surveys-gps-and-ccgs (accessed 6 September 2016)
2. NHS England The multispecialty community provider (MCP) emerging care model and contract framework england.nhs.uk/wp-content/uploads/2016/07/mcp-care-model-frmwrk.pdf (accessed 6 September 2016)
3. Rosen R, Kumpunen S, Curry N et al. Is bigger better? Lessons for large-scale general practice London: Nuffield Trust, 2016
4. Robertson R, Holder H, Ross S, Naylor C, Machaqueiro S Clinical commissioning. GPs in charge? London: The King’s Fund and Nuffield Trust, 2016

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