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Q&A with Nuffield Trust policy director Judith Smith: ‘In calling for an alternative contract we are suggesting something of a different magnitude’

How do you hope the report will feed into the ongoing NHS England Call to Action review as well as Monitor’s primary care access and competition reviews?

We agree with [NHS England chair] Professor Malcolm Grant that there needs to be a strategic conversation about the future of primary care, and it would be fair to say that the officials who commissioned this work view our new report as a contribution to that process. It has also become very clear that the regulators will play a major role shaping the climate in which innovative models either do or don’t emerge. Hopefully the UK and international experiences described in the report will be helpful to Monitor as it begins to think seriously about its own part.

Why a new alternative GP contract for local variation rather than building on the PMS contract?

The report describes the interesting ways in which various UK primary care organisations have used PMS and other local contracts to extend their range of services, in some cases even negotiating to have elements of hospital and community health services funding incorporated into the so-called PMS Plus. However in calling for an alternative contract we are suggesting something of a different magnitude. Specifically, one that is about a group of practices or a primary care organisation taking on a capitated population-based contract, and sharing risk for health (and ideally also social) care across the network of practices. The extent of services would likely be greater than with PMS, including say older people’s, end-of-life, long-term conditions, mental health and children’s care. It is critical that such a contract would specify outcomes and not the detail of local implementation - primary care networks and organisations need the freedom to craft the services and organisational arrangements that suit their local context.

Which aspects of primary care could be delegated for CCGs to commission?

Given the growing pressures facing primary care there is an argument for CCGs to be allowed to commission new forms of services over and beyond the core GMS and PMS contracts. Examples might include contracting for integrated programmes of care for people with long-term conditions, or for urgent and out-of-hours care. Networks of primary care providers, or other ‘scaled up’ primary care organisations, could bid to deliver such services (most likely in partnership with other providers), and these networks could include general practice, community pharmacy, allied health professionals and others.

Do you want competition regulation to be tweaked from its current form, or does Section 75 as it stands achieve what you’re proposing?

In practice much will depend on the capacity of Monitor to oversee the multiple commissioning decisions being taken at CCG level, and follow up on complaints from providers who feel they are being excluded from the market. However we do feel that the regulator needs to carefully consider whether the benefits of ‘at scale’ primary care provision are not compromised by concern about either the actual or perceived impact on choice and competition of practices working together in more collaborative ways.

If competition rules favour larger scale organisations, which they appear to do since April, what happens to smaller organisations?

Yes, it’s clear that the capacity of small practices to respond to competitive procurement will be limited and they will need support. This is where being part of a federation or network can really bring benefits to many smaller practices - they retain the autonomy of running their own practice, but can gain the benefits of organisational scale in accessing back-office support for procurement, service development and other functions. They can bid to provide additional services with others in the federation or network, or on their own, for example where a specific local service is required for a particular community.

Judith Smith is director of Policy at Nuffield Trust and a co-author of the report

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