new business models and primary care contracting

Our values: clinical engagement, patient involvement, local ownership, national support

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Primary care in an Accountable Care

Organisation (ACO)

Gabrielle Darby, Unit Head, New Business Models Group, NHS England

Paul Maubach, Accountable Officer, Dudley CCG

22nd November 2017




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Why are GPs considering accountable models?

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Trends suggest demand on general practice will

continue to rise…

33

The population in England is growing and age profile is changing – proportion of the population that

is over 65 and over 85 is increasing (48.9% and 113.9% respectively) (4). The number of older

people with care needs is expected to rise more than 61% in the next 20 years.(5) The share of

clinical staff contacts taken up by patients over 85 is growing, it increased by 16% between 2010/11

and 14/15 compared to 4% for 18 – 64 year olds.(6)

Demand in general

practice has been rising

historically

A growing and ageing

population could

further increase GP

workload

Estimates of a 10.5% increase in GP and nurse consultations between 2007 and 2015(1). Between

2010/11 and 2014/15 average list size increased by 10%.(2) The average number of consultations

per patient per year from 4.2 in 2000 to 5.5 in 2008 and in the over 75s from 7.9 in 2000 to 12.3 in

2008.(3)

The number of people with three or more long-term conditions is predicted to rise from 1.9 million in

2008 to 2.9 million in 2018.(7) LTCs account for about 50% of all GP appointments.(8) Intensity

could rise as complex care needs longer appointments, Hobbs et al found that mean duration of GP

consultations increased 6.7% to 9.22 minutes between 2007 and 2014 implying the 10 min

appointment system is nearing saturation point (9).

Changing burden of ill

health could impact

both volume and

intensity of workload

At the same time

patient expectations

are rising

The majority of patients (74.1%) contacting a surgery want to access a GP and in 2017 50% of

patients had a preferred GP. A survey of medical professionals across Europe showed that patients

expect higher standards, more information, more involvement in decisions and access to the latest

treatments. Person centered care and shared decision making have implications for demand on

GP time.

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… and that general practice will need to adapt to

meet this demand

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The 2015 GP Worklife survey reported the lowest overall job satisfaction reported by GPs since

2001. Reported levels of stress increased between 2012 and 2015 on all 14 stressors in the survey.

Reported levels of stress are now at their highest since the survey began in 1998.(1) A BMA 2015

poll of GPs found that 34% intended to stop working by 2020.

Attrition rates mean the

workforce may struggle

to meet demand

Stress and workload

are leading to burnout

and early retirement

During 2000 and 2010 the number of salaried GPs increased more than ten-fold (3). Two thirds of

salaried GPs work part time and in 2016 53% of the GP workforce was female. (4) NHS England

data shows a decreasing number of GP partners correlating with an increasing number of salaried

GPs (5). CfWI have modeled a range of scenarios showing that there is likely to be a demand-

supply imbalance by 2020 (6).

Nuffield / RCGP survey suggests a trend towards formal collaboration following the publication of

the Five Year Forward View with 63% of respondents saying they were in a collaboration and 44%

of respondents reporting their ‘main organization’ was formed in 2014/15 (7). NAPC now has more

than 200 Primary Care Home sites and there is real momentum behind ACS and ACO development

in the system.

Practices consolidation

and integration are

changing the provider

landscape

Technological

Innovations present an

opportunity if

harnessed early

Apps are starting to play a role in empowering service users, supporting professionals and

enabling specialist expertise to transcend geographical boundaries. We are starting to see

businesses emerging to offer online GP consultations.



5

There are some common themes to the models of

collaboration which we have heard from stakeholders

De-medicalise

model Value

professional

judgment

Value GPs handling

risk and uncertainty

Maintain GP relationship

with community

Look to reduce

inappropriate specialist

referrals and build

capacity in community

Holistic care for

complex needs

Generalist equal to

specialist

Measure quality by

patient experience

Personalised decision making

Whole population

approach

Support professionals to

focus consultations on

what matters to patients

Population

segmentation and

targeted approach

Prevention – more

focus on keeping

people well

Recognise social

determinants of healthSelf-care and

patient activation

GP leading a wider

clinical team

Give flexibility for

GPs’ preferences

Strategic redistribution

of medical work

Risk concentrating

complexity in GP role

GP provides expert medical

overview like hospital

consultant

Upskill wider team

Invest in dataConnect to

community assets



These models form the corner-stone of system-wide

accountable care

• ‘Accountable care’ is a term used to describe accountability for using a defined set of

resources to provide the best possible quality of care and health outcomes for a defined

population.

• The care model, centred on general practice, is by far the most important aspect of

developing new arrangements.

• It is possible to develop a care model through collaboration but in some places

commissioners have decided that sustainable implementation of the model with clear

decision rights and a single re-deployable budget to deliver it requires a new contract, rather

than relying on goodwill.

• Some areas (particularly some of the MCP and PACS vanguards) wish to establish

contracted-for Accountable Care Organisations (ACOs)

• ACOs need to either directly encompass general practice – through sub-contracting with GP

practices or employing primary care staff (or a mix of the two) – or there needs to be a very

strong integration agreement between the ACO and local GPs.

• ACOs vary in scope. E.g. an MCP is largely based on out of hospital services, whereas a

PACS has a wider scope as it brings in acute services.



Types of accountable care models

Collaborative

change

Small scale

Primary care

network

ACO – fully

integrated

Single contract with

integrated budget (inc

core primary care)

Virtual MCP or PACS ACS

ACOs are organisations

with a new contract,

rather than collaborations Structural

change

Large scale

ACO – partially

integrated

Integrated contract

aligned with GMS/PMS

practices





What is a virtual model?

• This is one of the more common approaches sites are taking

• The virtual model allows local providers and commissioners to collaborate to deliver an MCP or

PACS, a primary network or other collaboration

• The Alliance Agreement sits on top of existing contracts (such as GMS/PMS/APMS for General

Practice but does not replace existing Contracts.

• The Alliance is signed by all the participants in the virtual model, but does not overrule existing

bilateral service contracts.

• It enables integration between the providers who agree to a shared vision, operational and

resource commitments.

• It’s possible for commissioners to included as part of, or remain outside, the alliance

GMS / PMS /

APMS Contracts

Commissioners

NHS Standard

Contract

NHS Standard

Contract

NHS Standard

Contract

NHS Standard

Contract

Acute

provider

GP

practicesCommunity

provider

Mental

health

provider

Voluntary

sector

providers

ALLIANCE

AGREEMENT



Beacon Medical Group – NAPC Primary Care Home

Model Primary Care Home

Contract length Lifetime (PMS contract duration)

Population 39,000 patients across Plymouth and South Devon

ScopePrimary care, social care, public health, community

healthcare, mental health

Annual budget Total health spend for population - £46.7m

Stage of

procurementIn action, considering progress to Virtual MCP

GP integration Primary Care Home is led by the GP practice

Social care

integrationSocial care part of an integrated health and social

care provider and fully engaged.

Notes

As a rapid test site for the NAPC Primary Care Home Programme Beacon Medical Group have

developed a care model which will:

• Increase levels of health activation and community level support for our patients in partnership with

our patient groups, community pharmacy and the voluntary sector

• Provide outpatients support within our community as a practice and in conjunction with secondary

care

• Develop an integrated and flexible team around our most vulnerable patients through virtual ward,

enhanced care homes support and liaison psychiatry





What is a partially integrated ACO?

• In areas procuring ACOs the most common way that GPs are looking to engage is through partial

integration, and also through some direct influence within the ACO’s governance

• In this model GPs keep their existing GMS/PMS/APMS contracts and remain separate entities from the

ACO.

• An ACO Contract is awarded for all services in scope excluding core general practice.

• Practices sign an Integration Agreement with the ACO – an agreement that sets out how the practices and

the ACO will work together to deliver the integrated care model.

• The Integration Agreement sets out their commitment to a shared vision, sharing resource and devising a

joint workforce, estates, IT and care pathway design strategy.

ACO

Commissioners

Integration Agreement

GP practice 3

GP practice 1

GP practice 2

GMS / PMS Single contract – up to 10 years





What is a fully integrated ACO?

• This model represents the fullest form of contractual integration, and so provides practices with additional

choices. At the point when the first ACO contracts go-live there will be relatively few fully integrated

practices but that may change over time.

• In the Fully Integrated model an ACO Contract is awarded for all services in scope including core

general practice. This means that for the first time Primary Care, Social Care, Community and Mental

Health, and some Acute services can be delivered by a single provider holding a single contract and a

single budget.

• In this model, GPs suspend their GMS/PMS contract (with right to return at a later date) and enter into

the ACO as subcontractors or employees.

• Primary care funding flows into the ACO as part of the integrated budget

ACO

Commissioner

Single contract up to 10 years



Dudley case study

12

Model MCP

Contract

length10 years

Population Resident population, c.315,000 people

Scope

Community healthcare, some outpatients, UCC and out of

hours, primary care, mental health, learning disability,

intermediate care, CHC, end of life, voluntary and

community, public health, adult social care (phased)

Annual

budget>£200m

Stage of

procurementProcurement execution in progress

GP

integration

Mixed; some partial, some full. 84% of practices, covering

87% of the population, actively supportive

Social care

integration

Adult social care and public health included in scope. ASC

to be transferred over contract life

Notes

• Dudley was selected to join NHS England’s Vanguard programme in early 2015, and has since worked

with local partners and stakeholders to develop the MCP.

• The MCP will have the right to determine how the integrated budget is spent to realise a set of outcomes.

• The contract will be designed to deliver these outcomes, and some payment will be performance related.



More details can be found on the

NHS England website:

www.england.nhs.uk/new-business-

models.

england.newbusinessmodels@nhs.

net.

For further information…

http://www.england.nhs.uk/new-business-models

mailto:[email protected]

new business models and primary care contracting

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