LMC CEO Briefing (Part 2) Two new types of primary care contracts mentioned in the NHS Plan

In my last article I provided a view on the options for practices outlined in the NHS 10-Year Plan. The Plan foresees three options for practices which will be determined based on the size of the practice and the model in which they wish to provide services across their neighbourhood.

Traditional model

Single Neighbourhood Provider (50k population)

Multi-Neighbourhood Provider (250k plus population)

In the last briefing we highlighted the stated intention that the traditional model of general practice would remain, the frustrations of GPC England in getting Wes Streeting, DHSC and NHSE to firm up the negotiations on the national core GMS contract; and what practices might do now to be ready for new opportunities highlighted in the Plan. Two new primary care contracts are headlined in the Plan.

Single Neighbourhood Providers

GPs will be ‘encouraged’ to work at the neighbourhood level within providers specifically designed for the delivery of services for populations of approximately 50,000 people. We don’t know yet if this is a fixed figure or if there can be some local variation. There will be early adopters of this model, particularly among those practices who already serve populations of this size and of those PCNs who are considering practice mergers to provide services at this scale. Once this new contract is published practices will have the option of converting their existing core contract into the new format. It is anticipated that this will be designed to make it easier for the new provider entity to secure and run contracts for other services particularly outpatient and community services.

It should be noted that this same objective can already be achieved using the existing NHS contracting models. The most obvious route would be to merge existing core contracts and to form a single provider. This may be within the structure of a traditional GP partnership working at scale, which many of the ‘super-practices’ have adopted, or there could be the option of ‘incorporating’ and novating the contract into a limited company.

This entity can then enter a wide range of contracts commissioned using the NHS standard form contracts, NHS standard sub-contracts from Trusts and contracts from other sources such as local councils. Alternatively, services can be commissioned at this level using the NHS standard form contracts (which expressly include schedule 2L which integrates the provisions of APMS contracts). This would allow for a single consolidated general practice contract across the neighbourhood. If an existing group of practices are interested in taking a lead in developing neighbourhood services there is therefore no need to wait until a new contract is formed. It is necessary to start the work involved in merging practices and designing the services you wish to deliver.

Those who take these steps now may be in a more advanced position to seize the opportunities which may arise from the new contract once it is published and, in any event, can respond to opportunities at the neighbourhood level without delay. It would also allow them to wait for the outcome of the GPCE contract negotiations to undertake a full comparison of the options available to them, without preventing them from the work of delivering the Neighbourhood Health Service.

Once the ‘early adopters’ have made this transition it will be interesting to see what incentives will be used to ‘encourage’ other GPs to move to this model. This is particularly important in the context of the negotiations regarding the core GMS contract and whether the government will attempt to include provisions which will inspire a further round of GP practice mergers and consolidation to form more Single Neighbourhood Providers. The work and cost involved in mergers should not be underestimated, nor should the time required to deliver it.

Multi Neighbourhood Providers

The other new contract option available to practices is to seek to consolidate at a larger scale covering a population of approximately 250,000, This is a much more innovative model being proposed within the Plan, certainly in relation to the provision of general practice.

The core functions are largely administrative which are being removed from the ICBs in accordance with the ICB model blueprint. These include services such as overseeing digital transformation, creating shared back-office functions, developing an estates strategy, and providing data analytics and quality improvement functions. The Plan also states that ‘they will actively support and coach individual practices who struggle with either performance or finances – including by stepping in and taking over when needed.’ A lot of focus has been given on this wording as practices could be taken over by this type of provider.

GP Federations and Foundation Trusts are possible organisations to take on these functions. In theory there is the option of a new form of NHS Trust to be developed specifically designed to hold and to provide general practice contracts. This is already permissible in existing legislation although the practice of developing such an entity would not be easy. It is certainly an option being discussed and explored in some locations across the country.

As with the single neighbourhood provider option the existing legislation and contracting structures do make this type of scale possible. The primary limitation is that Trusts cannot hold GMS contracts but other structures can. The new contractual structure may be very similar to the one published in 2018 for Accountable Care Organisations (“ACO”) which provided practices the right to opt in which would suspend their core contract with the option of taking it back if they were discontent within the ACO.

Some Trusts and GP Federations already hold GP practice contracts and there is no reason why they could not expand these services in areas where the traditional GP model is ‘not working’, however, if the intention of the government is to focus on the delivery of services within neighbourhoods it would seem unlikely that this level of scale will be the preference over the Single Neighbourhood Practice model. This type of contract may represent a safety net for many GP practices and in some areas, it may be the opportunity to completely redesign services to fully integrate with community and secondary care provision. There is no suggestion that this will be imposed and practices will need to decide as to whether this is what they want for the future of general practice services in their neighbourhood.

Where the Multi Neighbourhood Provider is likely to have a bigger impact on practices will be with the commissioning of services. It is highly probable that these structures will hold contracts commissioned by the new, streamlined ICBs, and will sub-contract services across their neighbourhoods. In areas with established Single Neighbourhood Providers this is likely to be a relatively straightforward arrangement. In areas where practices operate in a more traditional environment some practices may find that they lose revenue streams and opportunities. This could in theory include existing enhanced services which have been traditionally provided at practice level. By way of example, the option for PCNs to collaboratively develop and deliver vaccination hubs has been adopted across many PCNs. This could be made mandatory and could be applied to all services commissioned locally.

Practices must therefore ensure that they have strategies for engaging and working with these organisations and structures as they are established in their areas.

William Greenwood

Chief Executive