The road to MCPs - Primary Care Commissioning

The road to MCPs: experts assess the new model of
care sketched by the Five Year Forward View
PCC recently assembled leaders of several
provider organisations to debate the
prospects for multispeciality community
providers (MCPs), writes Chris Mahony.
MCPs are one of the organisational
options outlined in the Five Year Forward
View. The other is integrated hospital and
primary care systems (dubbed primary and
acute care systems – PACS).
Participants had voiced fears the NHS is
again concentrating on structures rather
than culture and that there is some
uncertainty - even fear - about the future
shape of provision.
Success will only come from mutual
respect of each sector’s contribution.
While recognising such concerns, PCC
chairman David Colin-Thomé, who chaired
the event, said that NHS England chief
executive officer Simon Stevens did not
talk about prescribed models.
“We do not want to be told in a
challenged health economy that ‘this is
the model’. That’s how we got into this
problem in the first place,” the former
Department of Health primary care lead
said.
Paul Smeeton, chief operating executive
for the community services division of
Nottinghamshire Healthcare NHS
Foundation Trust, suggested the forward
view was “quiet on the importance of
culture and history in local health
economies” and there was limited
recognition of community and mental
health providers.
Agreeing that the review and subsequent
discussions had triggered uncertainty,
Smeeton said: “I have heard fears that GPs
will take over hospital services or that
hospitals will take over primary care.”
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David Colin-Thomé
Louise Parker, head of commercial
development for Medway Community
Healthcare, said: “There is a fear that we
will do what we always do and
concentrate on the structures while
ignoring the pathways and culture.”
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The road to MCPs
Dave Branford, chairman of the English
pharmacy board of the Royal
Pharmaceutical Society, said: “My
perception is that a lot of people have not
got a clue what all this means…I have
spent my whole life in the NHS and I still
struggle to say who employs who; who has
the money now. I am finding all this a bit
bizarre…Pharmacy commissioning is
already so labyrinthine.”
There was some consensus that pharmacy
and specifically pharmacists should play a
much greater role in evolving primary and
community services.
However Simon Mathias, service
development manager with the parent
company of a large community pharmacy
network but speaking in a personal
capacity, cautioned that the profession
had to do more to press its claim for parity
in the new NHS.
Sally Simmonds
“Pharmacy has never said what it can do
as opposed to what it could do. It has
never gone out and done the modelling.
What can we do to show we are able,
capable and competent in a relatively
short space of time?”
PCC development manager Sally
Simmonds noted that pharmacies are now
themselves being urged to federate
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though there was little evidence to
support the move at this stage. Pharmacy
may instead see that working closely with
developing GP provider organisations may
be the best route at present.
Colin-Thomé said he would be happy if
community pharmacy set up their own
federations as an often necessary
developmental step to a future enhanced
role.
He suggested GP arguments against an
enhanced role for pharmacists are similar
to those made by the same professionals
opposing increased roles for nurses a
couple of decades ago.
Branford noted that some federations are
starting to employ pharmacists but
generally questioned whether the model
would get the most out of pharmacy.
“How does a federation enable pharmacy
to collaborate? We, like some other
professions, were cut out by the Health
and Social Care Act yet we have such a big
role in long term condition management
and in care homes – which is our biggest
scandal.”
He said that with thousands of highlyqualified pharmacists continuing to
emerge from a large number of pharmacy
schools the system was at risk of ignoring
a vast pool of talent and knowledge that
could relieve the burden on general
practice.
“A lot of primary care organisations are
slowly waking up to find these people
could be amazingly helpful. GPs are
desperate for people in their surgeries to
work out problems with medicines.”
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The road to MCPs
Parker said that any further development
of the model of primary care would
inevitably require leadership and major
contributions from professions beyond
nursing – with pharmacy a prime example.
The rapid development of GP federations
was a key issue for several participants,
hardly surprising given it got significant
attention in the forward view.
Phil Yates, chairman of one of the earliest
and most successful federations, Bristolbased GP Care, and chair also of the new
National Association of Provider
Organisations, said his GP colleagues in
the south-west originally “had a big
ambition to transform primary care”.
Colin-Thomé said such approaches
“enable those secondary care clinicians to
take some responsibility for redesign”.
Federations should not “take over” but
they could be a “useful building block of
general practice”, Colin-Thomé suggested.
“For years many of us have wanted
general practice to remain small as a
community resource and concomitantly
be big as an alternative to the hospital
centric model,” he continued.
Dave Branford
“But we never had the cash to do it and
we therefore focused initially in pulling
services out of the hospitals.”
GP Care is now using cash from the Prime
Minister’s Challenge Fund as part of the
One Care Consortium to support primary
care and deliver general practice at scale.
The consortium includes out-of-hours
provider Brisdoc.
“We felt the messages were not getting
through to the centre and that is why we
formed the National Association of
Provider Organisations (NAPO). We are
very interested in being part of an MCP.
We could use One Care and pull in the
three community health providers.”
Partly by using secondary care specialists
to deliver services in the community, the
federation has not destabilised local acute
hospitals – which Yates said were already
facing financial challenges. GP Care also
uses chambers of consultants.
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Robert Flack, chief executive of Kirklees
community health provider Locala, said his
organisation had a “really tight
relationship” with the local federation but
it required a leap of imagination for
fledgling federations to see themselves as
leading MCPs”.
“It is less of a major leap for us but there
more to do about what is the right model
of primary care.”
“We need GP partners to become part of
us but their reaction to that would be
negative. Some larger practices are saying
that with the challenges of pensions, PMS
arrangements and the contract they can’t
see a future for current primary care so
they want to come up with a new model.
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The road to MCPs
“We need a fundamental rethink with GPs
about a new model of primary care. For
instance, we might need to close branch
surgeries because they are not financially
sustainable. That all requires different
skills, different commissioning and
different forms of organisation.”
Parker agreed that “there is not one
model that should be followed across the
country - hybrids work.”
“Federations still have the same
challenges we had during fundholding and
practice based commissioning. But the
pressure is now also on larger practices as
GPs are looking for new opportunities in
less pressurised environments,” she said.
Forms of ownership for organisations that
consider themselves part of the NHS
family could also be important, several
participants suggested.
Flack said: “It makes a big difference to
staff that we are a mutual and that they
are around the table in our MCP
conversation. We have worked very
closely with the mental health trust on the
concept of an MCP.”
He added that since the review he had
been “hearing all the right things but will it
be real”?
A policy vacuum exists around contractual
mechanisms in primary and community
care, he warned.
Yates said: “I want an MCP to be an
integration of care across the system but
we need the logistics behind the service.”
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However he also cautioned that thought
was needed on unintentional
consequences of changing the primary
care system.
“We might lose the independent
contractor model,” he suggested.
When Flack commented that “we need a
culture about the community” he kicked
off a discussion about a perceived
continuing failure to recognise the knockon effects for the system of underinvestment in community and primary
care services.
Recalling his time at the DH, Colin-Thomé
said at that time hospitals failed to
recognise that 40% of breaches of trolley
targets involved older people.
“It was crying out for community service
development but the hospitals could not
see that.”
Pointing to the declining share of NHS
spending allocated to primary care, Yates
suggested that the NHS has still not
recognised the link. Meanwhile, Lance
Gardner, chief executive of the Care Plus
Group, said “the race to the bottom in
social care” was a further worrying
symptom of under-investment in
preventive and early intervention services.
Gardner emphasised that the community
health and social trust he leads in northeast Lincolnshire now works in partnership
with other organisations, including the
acute trust and GP federation. This meant
surrendering some individual sovereignty,
he said, but this would be key in new
models.
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The road to MCPs
He continued: “If the hospital fails the
four hour target it is the responsibility of
all our services. We are being collegiate
about the problem and working with our
partners rather than fighting each other.”
With six organisations now “all in the
same room” and weekly meetings of chief
executives to resolve problems, he
continued, the next logical step is a joint
venture.
“In applying for a grant recently we had to
put in six lots of accounts, get six sets of
legal advice. We now see commissioning
of systems rather than services because
we do not want commissioners to have six
conversations with six providers.”
He noted however that further integration
and development could yet be hindered
by regulatory issues.
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“The CQC is saying that we are different
and therefore high-risk. That is
discriminatory – we want to be different.”
Reflecting on the range of models already
developing or in place, Colin-Thomé ended
the session by suggesting providers should
be less nervous of the view from the
centre.
While the authors of the forward view are
unlikely to let a thousand flowers bloom,
well-tended variations might well receive
official support, he suggested.
March 2015
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