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.” www.pcc-cic.org.uk 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.” © Primary Care Commissioning 2015 1 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 www.pcc-cic.org.uk 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.” © Primary Care Commissioning 2015 2 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. www.pcc-cic.org.uk 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. © Primary Care Commissioning 2015 3 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.” www.pcc-cic.org.uk 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. © Primary Care Commissioning 2015 4 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. www.pcc-cic.org.uk “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 Primary Care Commissioning (PCC) provides training and development services for health and care commissioners and providers. www.pcc-cic.org.uk/services © Primary Care Commissioning 2015 5
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