It’s tough for GP practices, with their share of the overall NHS budget at the lowest in a decade. The 10 Year Health Plan signals a major shift to more care in the community and with assurances about the future of the partnership model and General Medical Services (GMS) contracts the future should look positive. However, there is a hill to climb in the current year, with little funding to help.
Helen Northall
On top of this there are must dos:
- Same-day urgent access – a same-day response for all requests identified as clinically urgent
- Access using modern general practice approaches
- Enhanced prevention – including expanded childhood vaccinations, obesity and diabetes targets in the Quality and Outcomes Framework (QOF), and participation in the lung cancer screening programme
- Digital integration: including interoperability with the NHS App.
On top of this the expectations for primary care networks (PCNs) who need to morph to deliver neighbourhood health – include:
- Working with the integrated care board (ICB) to align with local authority focused neighbourhood boundaries.
- Leading/participating in multi-disciplinary teams
- Use risk-stratification tools to identify and prioritise vulnerable cohorts (e.g., frailty, complex long-term conditions) for continuity of care.
In addition, the neighbourhood provider contracts are on their way,
- Single neighbourhood provider (SNP): Population circa 50,000
- Multi-neighbourhood provider (MNP): Population circa 250,000+. These may involve GP Federations or alliances of PCNs.
However, the questions that need to come before size (and indeed form) is what is the collaboration or organisation going to do at which levels, and why? How can practices position themselves well for the future?
Only when this is clear can the appropriate size be considered – and one size/model does not fit all. As implementation of the 10 Year Health Plan moves forward. I envisage that there will be various collaborations set up for different purposes, working with different stakeholders depending on what is being delivered. This may include joint ventures with trusts or alliances – particularly as integrated health organisations (IHOs) develop, this could reignite some of the innovation and collaboration last seen during fundholding times. There is an opportunity now to start this work and get GP practices in the driving seat.
Thinking through the best way to deliver locally is crucial.
For continuity of care and to support the people that may make the most demand on the health service the GP practice may be best placed to co-ordinate support, which for some services will be provided at neighbourhood level, to individual patients. List based general practice is crucial to support the frailest, those with multiple long-term conditions, and those who are, or are most likely to be regular users of A&E or bed days. The ability to identify this cohort and coordinate proactive care, responsive care and targeted support out of hospital is crucial if the NHS Medium Term Plan goals of reducing acute unplanned demand is to be realised.
When looking at population health for a local area, a size of about 30,000 to 50,000 may be a better footprint. This is approximately primary care network size and, as has been signalled in the Neighbourhood Framework and other documents. Subject to consultation, PCNs, with maybe a few geographical adjustments, are likely to be the footprint for SNPs. At this level workforce resilience and robust plans for practice business continuity can also be well managed to support individual GP practices.
An ability to work at a larger scale – perhaps helping practices with back-office support and working collaboratively to provide services such as urgent/same day care hubs, maybe diagnostics in the community, perhaps in neighbourhood health centres, home visiting and some community-based services, for example mental health and/or frail older people services This is the space many federations are currently working within very successfully. Many federations are also able to support practices in difficulty, helping them become resilient again and/or brokering local solutions to keep the contract within the local community of practices. These could form MNP foundations.
However, beyond this to deliver the most significant shift of services into the community we may need collaborations of federations/MNPs that work across trust footprints to support the redesign of care pathways, optimise diagnostic pathways and similar. This is where opportunities to make significant change lie that could achieve win-win financial outcomes and make the best use of the expertise and capacity available.
Trusts are focused on addressing urgent care pressures, waiting lists and financial balance – so engaging on these areas may be a way to start dialogue. Collaboration with social care to support people out of hospital and enable earlier discharge may work well at this scale, relieving pressures on hospital beds.
Groups of federations or MNPs who can engage with trusts to find solutions will place themselves well for the future. If win-win solutions working in partnership with trusts can be identified now and put in place this will also support potential future working, should integrated health organisation (IHO) contracts be let to the trust. In the meantime, trusts could use subcontracts to fund workload that is moving to the community.
Developing these relationships will help the potential development of future alliances and joint ventures, with trusts and other partners, to ensure general practice is at the table and actively influencing a positive future for general practice. It’s a stretch to start now, but can position practices well for the future, developing future working relationships and trust between partners on the journey.
At the core of scale is the primacy of list based general practice, underpinned by the GMS, Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS). An important step is to build governance mechanisms for these individual practices to have the means and agreement to work at the levels of scale that make sense locally.
As the implementation of the 10 Year Health Plan progresses flexibility to work at different levels is likely to be an important factor. Rather than considering form as the starting point, thinking through with stakeholders what needs to be delivered, and developing collaborative relationships with those you need to partner with to deliver these services should come first.
Just get started, even at a small level, and look for gain share opportunities that help resolve shared problems.
Contact enquiries@pcc-cic.org.uk to talk to us about how we can help you position your practice or PCN well for the future.
Author Helen Northall, chief executive, PCC.
