New GP contracts don’t come along every day, although they do seem to be adjusted on an alarmingly regular basis and sometimes not for the best. So what is the new MCP (multi-speciality community provider for those of you who have emigrated to Mars, or perhaps read Pulse less often than we really should) contract all about? Is it a good idea and should we all be rushing to sign-up for one?
My wise and articulate colleague at the GPC, Dr Simon Poole, said there were three things his trainer pronounced that stuck in his mind (which is certainly probably two more than I remember, though that may be more a reflection on me): we have a registered list of patients, a contract in perpetuity and a clear divide between what is good for our patients and what is good for our bank balance. So reading the small print and probably actually most of the large print, this new contract seems to be breaking some, or perhaps even all, these golden rules.
If you’re drowning, a water logged broken branch can look attractive
The MCP contract is about integration; it is probably fair to say that the current boundaries make it harder (though not impossible) to provide care that is both of high-quality and seamless. A new contract should simplify the current system, improve patient outcomes and give GPs the opportunity to work in a more flexible way, focused on those things that really matter both to staff and patients. The theory propounded is that an MCP will offer such economies of scale, such significantly better integrated team working and such improved technology, that the GP time will be suddenly freed up. Patients will always be directed to the most appropriate professional, allowing us to neatly step or even run off the 10-minute appointment treadmill, allocating more time to our more complex patients and those with diagnostic uncertainty.
Sounds good and sensible so far, though a little voice somewhere is whispering, will this really reduce the tsunami of patients heading in our direction, or merely open up new avenues of demand, leaving us to drown in that aforementioned complexity? Let’s hope not and that the vanguards have truly proven the case for such seismic change.
Leaving aside the philosophy, what about the nuts and bolts of the new contract? There are three versions on offer:
- Virtual MCP
- Partially integrated MCP
- Fully integrated MCP
Only the first will leave our current, very secure, though not perfect, contracts untouched.
The fully-integrated version puts all our current contract funding firmly into the pot, where there will be three possible core funding contributors: primary care, social care and local authorities/public health. These are pooled and can be diverted to the areas of greatest need, but in this new world, it could mean diversion to or perhaps away from general practice.
The NHS standard contract for MCPs (the NHS standard contract is a long and complex document, familiar to NHS providers, but not until now to most GPs) describes the whole population budget (WPB) based on the current commissioning spend. The WPB will exclude a top slice, probably 2.5-4%, which can be earned back by the MCP on delivery against agreed care quality and transformational metrics, in a similar way to hospital CQUINs. There will be a national and local element to this, with an alignment to the aims of the Five Year Forward View.
There will also be a gain/loss arrangement. This will incentivise more effective management of patients in the community, to avoid unnecessary acute intervention. So, an understandable aim for the MCP is to reduce demand in the acute sector (and perhaps one of the main reasons for introducing these changes), but is it remotely achievable with so many of the factors causing increasing A&E attendees and admissions being outside the control of general practice, especially with no additional funding on offer?
The partially-integrated model also, to coin a phrase, has ‘issues’. The crucial general practice contribution is described via an integration agreement. It is likely to include enhanced services and possibly a repurposed QOF. So GPs could be subcontracted to do this work, but perhaps not, as it will probably have to be procured and thus is far from guaranteed.
That then brings us onto (and apologies in advance) procurement and procurement law, happily up to now not on our top ten list of worries. Public contract regulations (PCR 2015) demands that contracts for clinical services with a lifetime cost of £590,148, must be advertised in the Official Journal of the European Union. This means that there is no guarantee that we will win the contract. These are complex and expensive contracts, indeed the integrated support and assurance process is mandated to support commissioners in making a robust assessment to the ability of any MCP to bear significant levels of financial risk and deliver a complex contract. So much for that simplicity.
So why then switch to a short-term contract, take on the responsibility of moderating demand, reducing avoidable hospital admissions and elective activity and taking on the lottery of large scale procurements? Perhaps our current situation is so grim that this still looks like a good option; if you’re drowning, a waterlogged broken branch can look attractive. Or perhaps for those of us with an entrepreneurial bent, there are risks here worth taking.
Nevertheless, the aims of dissolving the divides that exist between services provided by different parts of the health and care system is a good one. If we were designing the whole shooting match afresh (though perhaps I shouldn’t use that phrase, bearing in mind the current firearms furore) we probably wouldn’t start from where we are now. However to use NHS England’s own words: ‘Much of the MCP care model (in fact perhaps all of it) can be delivered in the current framework through closer working.’
We can, if we wish, form super-partnerships or very robust federations and then use these as the basis for sensible GP led integration with community teams, mental health, the local authority and even our consultant colleagues. The choice is ours, but for the sake of our patients and in whatever system we do choose, GPs must remain as the cornerstone of any system of accountable care provision.
Gavin Ralston is a GP in Birmingham and a BMA GP Executive team member