By Michele Petrie

“Having been at a Three Counties PM meeting last week it was very clear that a lot of PMs have no idea about MCPs and the implications for them and their practices. I summarised the BMA document for my Partners and thought it would be worth sharing here – it makes for interesting reading…. and at times quite scary really! Please remember, some of the comments are my own.” Michele Petrie

Overview

• MCP = Multi-Speciality Community Providers

• NMC = New Models of Care as part of NHSE Five Year Forward View trialled across 50 Vanguard sites, 14 of these are MCP vanguards (population based model of care that integrates primary and community health services, built upon the GP registered lists of the practices involved. Practices will have to combine together – either via GP network organisation or super-practice to create a combined practice list and bid for an MCP contract from their local commissioner. The MCP contract will be aimed at populations of at least 30-50,000 patients and as currently constructed will run entirely separately to the national GMS contract

Contracts

Three possible contractual paths, although NHSE will develop two model contracts, one for partially integrated MCPs and one for fully integrated MCPs:

• Virtual MCP – ‘alliance agreement’ with commissioning body which would overlay and not replace regular commissioning processes eg shared managing of resources, governance arrangements, risk sharing agreements, operational delivery of services. The services would remain governed by the regular commissioning procedures and contracts

• Partially Integrated MCP – single contract for everything that would otherwise be in scope of the full MCP, outside of core general practice eg. LESs, some DESs and QoF. Practices would still hold GMS contracts but anything beyond that would require them to form a joint legal entity in order to bid for the contract of any services (already have this with Taurus). The legal agreement sets out the additional obligations but the MCP would be allowed to subcontract services to non-member practices.

• Fully Integrated MCP- primary care and community services procured in a single contract between a single legal entity and the relevant commission bodies holding a single whole population budget. The full MCP contract would take the form of a hybrid GMS/PMS or APMS and the NHS Standard Contract held between the MCP and the commissioning bodies relevant to the respective service specification. Contract would run for a limited period of 10-15 years and include an early break opportunity. GPC has highlighted the importance of practices being able to maintain their GMS contracts. NHSE have investigated an amendment to primary care legislation, which for full members of the MCP, would allow for contracts to be ‘suspended’ for a defined period of time that aligns to the MCP contract term and an option to reactivate this at a later date. This does not address any practical implications of such a switch eg, estate ownership.

Service Specification

• Individual contract will define the exact range of services to be covered within the boundaries of the national set minimum and maximum parameters.

• Specification will consist of national requirements, core elements of the MCP care mode and local service requirements and standards. To maintain some degree of consistency nationally local variations will follow a set of standard terms from which MCPs can tailor their service spec.

• Potentially all health services that do no need to be delivered from a hospital could be in scope of the MCP. The MCP will also become responsible for managing hospital activity levels within these geographical areas (no discussion about how this would happen as far as I can see)

Funding

• MCP funding proposed to comprise of 3 main components to create MCP contract sum:

• A base £ per head for the MCP’s registered list (ie. The combined lists of all constituent practices) to create a single who population budget. Initially calculated over the scope of the service specification, intended to be multi-year and adjusted in line with changes in CCG allocations. Expectation that MCPs will become more efficient over time and that will be reflected in the funding!

• Performance pay – Whilst the MCP will not be subject to QoF there will be performance related pay system in place, set for the MCP as a whole, with details of how it fulfils the criteria internally up to the MCP itself. MCP pay for performance scheme will recycle monies from existing QUINN and QoF scheme constituting up to 10% of MCP contract value.

• The effect of any risk sharing agreements with local acute providers which will complement the whole population budget eg. an aim to reduce avoidable activity in secondary care

Procurement

• Procurement of a full MCP contract opens up a number of problems. Under EU law from 01.04.16 anything over £750,000 has to go to open tender. Possible risks – MCP organisation may not necessarily win the MCP contract for their area and the framework mentions that procurement law would need to allow a range of organisations to set up MCPs including non-GP led bodies such as Acute Trusts and commercial organisations.

• NHSE proposes that the initial PIN (Prior Information Notice) put out to advertise the contract would encourage prospective bidders to demonstrate that they had the support of local GPs (and GPs could support more than one bid if they so wished) however this does not mean that GPs have preferred provider status but also that under no outcome would they lose their right to continue to provide medical services!

• NHS Improvement is minded to retain these procurement rules despite the UKs decision to leave EU

Right of Return

• NHSE proposes that MCP practices retaining their existing contracts in a suspended form would enable a right of return to their previous arrangements should they wish to leave the MCP. However once a practice joins an MCP it is hard to envisage how they could effectively or easily disentangle itself unless the legal structure of the MCP is such to ensure a practice can disentangle its patient list, finances, premises and staff especially a few years into the project. If a practice did leave they would then be in competition with a much larger rival provider in their immediate area. More work with GPC and vanguards to look at this.

Other Considerations

• Employment models and conditions – there is no explicit mention of what employment models should be utilised within MCPs. NHSE is clear that each MCP will be allowed to organise its workforce as best fit meaning locally negotiated contracts. As the contract will not be GMS it is presumed that the requirement of offering terms equal to the model salaried GP contract will not be retained unless they are employed by an individual practice which maintains an active GMS contract.

Regulation

• Proposed that CQC would inspect the MCP as a whole rather than the individual practices aiming to reduce the burden on individual practices but a decision would depend on the exact organisational model of the MCP.

Indemnity

• NHSE and DoH will work with NHS Litigation to provide information to potential MCP providers on their options of securing cover. This removes costs from individuals transferring them to the MCPs corporate body. No detail on this as well as the treatment of VAT though.

Pensions

• Concern that where MCP is lead provider and GPs etc are sub-contracting these would not be pensionable for the purposes of the NHS pension scheme. It has been arranged that the regulations will be amended to allow GMS contractors to pension subcontracted income subject to certain conditions (but we don’t know what these are yet!)

GPC Approach

• Vital that practices are able to be involved in an MCP while retaining their GMS contract and NHSE proposals for virtual and partially integrated options are extremely important. Number of concerns about the MCP contract proposal:

• National specifications to stipulate basic elements of GP which must be provided by all MCPs does not go far enough in ensuring a consistent standard of care to patients regardless of postcode. Anything that threatens to disrupt this needs to be considered with great care

• Feel it is inappropriate for flexabilities and freedoms from national standard contract requirements to apply to core GP. A significant move towards locally determined contracting could undermine the collective bargaining rights for remaining GMS practice

• MCP contract is likely to go through an open procurement process. This raises the real prospect of GP services being outsourced to private corporate entities via MCPs with no guarantee that such an open procurement process will result in local GP led organisations winning the resultant contract. In such a situation local practices would potentially find themselves set in competition for patients against the emerging MCP body commissioned by NHSE.

• Right of return is complicated – practice premises may have changed hands, staff may have been transferred to the MCP organisation, in a full MCP registered lists may have been merged and it is not clear how this would be disentangled, no guarantee for practices to return to their contracts for services beyond core GMS, practices leaving pose a sustainability threat toremaining MCP, practices that do manage to leave will find themselves in direct competition for patients from much larger organisations

• Should GPs decide to move away from existing GMS contracts to locally defined arrangements then spending on core services should be defined and ring fenced within the wider budget. Without this basic level of protection core services could be put at risk by debts in other parts of the health service, budgetary constraints or unforeseen overspends on non-core services. Risk is high at MCP level. Spending in primary care has continued to fall and the likelihood that without this protection this could get worse. A ring-fenced floor for core general practice spending would allow MCPs to invest additional resources in essential services as needed. Failure to ring fence primary care spending will act as a disincentive for GPs.

• Practices will need to be careful in ensuring that an MCP arrangement into which they enter is based upon solid organisational and legal foundation and ensure they are aware of any potential implications of the MCPs development including being put at personal risk of bankruptcy because of the wider deficit of the organisation for which they are now accountable.

• GPs will also need to be clear about their role and terms of employment.

• Practices should not be pressured into making any hasty decisions at this stage and should be wary relinquishing their GMS contract and together with LMC should put forward proposals for participation in MCPs under current contract.

• MCP is currently aimed at being voluntary although there exists the possibility that practices may feel pressurised into signing up either by commissioners or other practices. If practices feel uncomfortable with proposals that are put forward then this should be discussed with LMC.

GPC Approach

• Feel MCPs could flourish if built on the foundation of a continuing national core contract for GP. Greater collaboration and integration is feasible with a core contract in place.

• Service delivery element of the MCP proposal – functional integration between primary and community care – is already partially delivered in some areas under contractual arrangements with practices working closely with community teams.

• Membership of a GP network GPs can get involved in the provision of a wider range of services, multi-disciplinary work and greater specialisation. This would provide all the financial incentive needed to fulfil MCPs objectives without any need to subsume core contracts

• Maintaining national core contracting and using new contracting methods for other services, as now with enhanced services, would provide foundation for GP confidence.

Thank you to Michele Petrie for this article. The full documents can be seen here.