GP practices at the core of pathways
Dr Oliver Bernath explains how he is working with GPs to set up provider organisations for long-term conditions that can deliver savings for commissioners.
There are three ways a commissioner can save money. The first is to shut down a service – the easiest, but obviously the worst thing to do. The second is to keep patients healthier through public health functions. This option is limited, however, by the growing elderly population. The third option is to run services more efficiently – reaching more patients, at a lower cost – which is what our model favours. This not only reduces demand but where the demand is still there, creates processes that are cost-effective in delivering care.
GPs' unique position
Primary care is the central hub in managing long-term conditions. GPs can ensure better controls over the entire care process along a year of care, across all providers.
Their unique selling point is that GPs are able to tighten consistency in care quality and reduce unwarranted variation in clinical outcomes and care costs.
Managing longitudinal care processes for patients seems very much a GP provider's job – they make sure Mr Smith's HbA1c gets checked, his retina screened and so on.
Right now it would be quite a difficult task for the commissioner to go to all local GP practices, with their inconsistencies and differences, and pull them together without it becoming a top-down approach.
My company, Integrated Health Partners (IHP), facilitates a model where GPs can set themselves up as providers with IHP as a joint partner. To create access to start-up funding, these GP provider organisations (GPPOs) can also access another separate organisation we have created – Health Impact Finance (HIF) – which oversees a start-up fund using social investment funding.
The two can overlap but this is not mandatory; GPPOs do not always need start-up funding and the HIF fund can be used by other NHS bodies, not just GPPOs.
The GPPO model we are close to finalising involves GPs providing primary care services for patients with long-term conditions in their practices. GPPOs take on this work instead, in their practices, in a better and more cost-efficient way (see box, page 24).
The model makes life easier for commissioners because they are reassured quality of care will improve and that they will get a fixed package of services for a threshold of patients to be treated, for a set price.
The commissioners are able to say they have made sure the GPPOs are available in the market and meeting quality standards, at the right price – but it is the GPPO's job to make sure the care reaches all the patients, and it reports back to the commissioner that thresholds have been met.
The payment tool used depends on what is preferred locally. So the commissioner could use a LES as the payment mechanism for getting the GPPO to provide these additional services.
If services are not primary care services, a procurement process is necessary. When Year of Care tariffs are introduced in 2014, these can be used to determine prices.
There is no profit share of savings made – the model is simply the commissioner paying GPPOs to provide additional services in their practices. Savings made remain with the commissioning group.
For practices to try to provide more services themselves still requires co-ordination and process controls, and that is what my organisation, IHP, provides to GPs looking to create GPPOs.
We see ourselves as joint partners who make sure projects are implemented, until we are not needed any more or we move onto a new topic for the organisation.
Our work with GP groups is not fancy rocket science with clever computer programs – it's very nitty gritty stuff; a lot of sharp pencils, paper and talking.
At some point, GP providers will need big data collections, but mostly our work involves going into practices and seeing how they do things, and then enabling better dialogue and communication between practices, consultants and community matrons.
We're not trying to invent fresh pathways – many best practice guides are available from NICE. But we can unpick the disparity between best practice guidelines and what happens in practice.
It's not our vision that a GPPO will take on large-scale hospital services or completely replace a community provider. The bulk of care that needs to be taken out of hospitals is long-term condition management, for patients already being taken care of by the GPs, so the GPPO will focus on doing a bit more of that care, in a better way.
So there is not really much of a conflict of interest between GP commissioning and GPs providing in this model.
If a GPPO offers a broader range of services, then those services will be procured through public tenders and patients will have choice.
Our explicit aim is that GP practices remain independent enterprises because we believe autonomous local practices are a major strength of the UK's healthcare system, rather than them being taken over by much larger organisations.
GPPOs can get started without any qualified provider (AQP) status as long as their remit is limited to what can still be considered primary care. If a GPPO wants to expand its services, it could obtain an AQP licence and bid for tendered services. Our main goal is to get proper management of procedures and processes into primary care without forcing primary care to form a large corporate chain.
Our costs are probably similar to independent contractors seconded to PCTs. By working with a number of groups we can offer scaled benefits on IT, such as risk stratification tools or iPad-enabled care plans.
As part of providing more services to patients with long-term conditions, GPPOs might need some start-up funding.
Mostly this is needed for additional staff time or freeing up practice managers for additional data management or allowing the GP to have ring-fenced time outside their normal remit to review things.
Such funding is scarce in the NHS. SHAs top slice budgets by 2%, supposedly for innovations, but wherever I look, it seems to be used for bailing out overspent commissioners.
That's why we created the concept of health impact ‘bonds'. These will be run along the same lines via the social impact bonds that have been used in the UK since 2010, by allowing ethical investors to fund schemes such as mentoring of released prisoners, foster care for children previously in care homes, and help for rough sleepers (see socialfinance.org.uk/work/sibs for more information).
The idea is that social investors can put money into a fund, which then invests in, say, a frail elderly care programme. Any GPPO or other community provider could apply for funding of working capital for the short term until their project becomes self-sustaining. Only when the project generates savings will the funding be withdrawn and the commissioner, whose expenditure went down as a result of the project, can pay back the fund.
However, the financial risk remains with the fund. In that sense, these are not really bonds as there is no fixed obligation to repay should the project fail.
A GPPO could apply for a few million pounds for the two or three years needed to get a project off the ground. The funding would not require any equity share in any new venture of any kind. The GPPO would need to show it had standing, with a board and governance.
It would not have to be a newly formed company. If it wanted to be a company limited by guarantee and have social enterprise not-for-profit status, that's most welcome.
Social investors fall into three groups:
- individuals who want to make a contribution to society, who will often say any returns should be kept in the fund for future projects
- large corporates or banks looking to restart charitable pots of money, which had been reined in immediately after the 2008 banking crisis
- charitable organisations that have in the past given grants without really knowing the outcomes, who want a little more control over their investment but who are usually happy for any returns to be reinvested.
The fund aims to make some return, but not at a commercial rate. It also wants a clear account of social benefits. A figure on expected returns has yet to be decided on. But there are investors ready and willing now to put money in, who are waiting for projects to approve.
Under the arrangement, the fund would sign two contracts – one with the provider organisation, setting out what is expected to be delivered, and the other with the PCT or CCG to say that, within well-defined metrics, certain payments will be due if targets are delivered and savings made.
Health Impact Finance is a separate organisation with different staff from IHP. It will be managed in a similar way to an investment firm – in that it would sit on the board of the provider to make sure the programme is delivered, have a governance oversight and also ensure anything that could detrimentally affect patient care is stopped.
Anyone can apply to this fund – you don't have to be working with IHP. HIF has an independent investment committee that evaluates applications.
Making private palatable
Integrated Health Partners's fundamental belief is that the NHS must stay a public service and GP practices must remain local and independent.
But as a doctor myself, I am happy to put ideological concerns aside if the involvement of a private organisation can overcome the hurdle of funding, or bureaucracy, in order to improve services. As long as the private organisation gets a fair price for their services, all is in the interests of the patients, and it couldn't otherwise get done, then it has to be a good thing.
The GP Provider Organisation journey
- GP practices decide they want to become provider organisation.
- The ideal-sized GP provider organisation (GPPO) covers around 100,000 patients.
- The GPPO decides to provide a diabetes service, for example, and sets itself up as a GPPO with appropriate board and governance arrangements in place. It can choose to become a social enterprise.
- The GPPO agrees with commissioners to provide a set number of services for patients with diabetes for an agreed price – for example, HbA1c checked X number of times, retina screened – and that it will provide these services for an agreed threshold of patients, most likely using a local enhanced service (LES). IN future, ‘lead providers' for long-term conditions services may be reimbursed through ‘Year of Care' tariffs due in 2014.
- All practices in the GPPO retain their independent structures.
- The GPPO puts together a plan for which practices will do what and when, co-ordinates clinics, helps identify gaps in care, introduces risk stratification tools, ensures input from community matrons/community services to ensure GPPO will meet its threshold and work through teething problems. In cases where IHP is engaged by the GPPO to support the process, IHP is a partner in the limited liability partnership (LLP) and receives a franchise fee.
- GPPO may decide it wishes to introduce more community matrons and can get start-up funding for this from a health impact ‘bond' funded by social investors. A GPPO does not have to use HIF funding.
- Fund requires two contracts to be signed – one with the GPPO saying it expects to provide x services and one with the CCG to say it agrees to make these payments if targets are met and CCG savings made. Investment bond funding is to provide working capital during the development phase. Once the service is self-sustaining, funding stops and the GPPO is then commissioned by the CCG. The CCG pays the fund the agreed payment.
- Savings remain with the CCG after it has paid the GPPO.
- Social investment funding is repaid by the commissioner.
- If the GPPO wishes to provide secondary care services, it must become an AQP provider and apply for CQC registration and go through formal procurement.
Dr Oliver Bernath is managing director of IHP