We have a radical plan for primary care

General practice is widely recognised to be the foundation on which the NHS is based. But practices are under increasing pressure because of rising demands from patients at a time when the share of NHS resources they are receiving is declining.

‘Strengthening the role of GPs as providers requires practices to collaborate in federations to deliver services at scale’

In a report published today, the King’s Fund proposes a radically new approach to commissioning and funding general practice to tackle this pressure. This starts from the premise that GPs are both providers and commissioners of care, and their role as providers is the more important of the two.

Strengthening the role of GPs as providers requires practices to collaborate in federations to deliver services at scale. It also means practices working closely with community nurses, health visitors, allied health professionals, pharmacists, paramedics and social workers in “family care networks” to deliver most forms of care other than specialist expertise best provided in hospitals.

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This includes ensuring that patients in care homes and nursing homes are not admitted to hospital unnecessarily and, where appropriate, that services are available 24/7 to enable a rapid response at times of crisis.

New organisations

Under our proposed approach, federations of practices would take on a population based capitated contract to provide care to patients on their registered lists. The funding in the contract would be based on the number of patients served and the range of responsibilities included in it. Funding for general practices would be incorporated with the funding for other services covered by the contract.

‘The networks might be close knit arrangements in some cases and looser alliances in others’

Under the contract, federations would be required to deliver outcomes agreed with commissioners. These outcomes would encompass population health, patient experience, access, service utilisation and financial performance. The focus would be on what providers are expected to deliver rather than how they should do it, giving practices the freedom to provide services in the way that best delivers the agreed outcomes.

Federations would need a range of capabilities to manage the contract successfully, including expertise in contract negotiation, financial management and oversight of clinical quality. Well developed clinical leadership and access to real time information would also be important to enable providers to keep within budget while also achieving the required outcomes.

Practices would need to create new organisations to manage the contract, drawing on current innovations in primary care described in our report. These organisations might include limited liability companies, community interest companies and social enterprises, and “super partnerships”. Robust governance of services and budgets linked to explicit accountability for performance delivered through the new organisations would be essential.

The decision makers

Clinical and financial risk management would require federations to cover populations in the range of 25,000-100,000 people. The actual size would depend on the scope of services covered by the contract and the extent of risk sharing between commissioners and providers. It would be important to be sensitive to the danger that larger organisations may find it more difficult than smaller ones to engage member practices and create a common sense of ownership and purpose.

Federations would use their budgets to commission services from other providers where this was appropriate. In taking on this role, federations would take “make or buy” decisions enabling them to provide most services in-house or alternatively subcontract with other providers in virtual networks. These networks might be close knit arrangements in some cases and looser alliances in others.

A major challenge in making this approach work is developing contracts and incentives “within network” to deliver the outcomes required. This encompasses how GPs are paid – by salary or other means – and how subcontractors are incentivised. Experience in other sectors where supply chains link prime providers and subcontractors may hold lessons for the NHS.

Take back responsibility

Federations would need to collaborate closely with some hospital based specialists to manage budgets successfully. Multispecialty medical practice holds out the prospect of substantial savings in the costs of hospital care because of the opportunity it creates to provide proactive care, rapid responses to crises and specialist care in community settings, which in the past has usually only been available in hospitals.

‘If GPs choose not to take on the new contract, then NHS trusts should be given the opportunity’

Responsibility for commissioning has been seriously fragmented under the coalition government’s reforms with the budgets previously controlled by primary care trusts divided between NHS England, clinical commissioning groups, local authorities and Public Health England. These organisations would need to work together to implement the new contract. Practices involved in bidding to provide services under the terms of the new contract would be excluded from the process of commissioning these services.

A significant investment in leadership and organisational development would be needed to support practices in working differently. Federations would also need to forge partnerships with organisations with skills not usually found in practices to be able to manage contracts and budgets successfully.

If GPs choose not to take on the new contract, then NHS trusts should be given the opportunity to do so. At a time when the need for innovation in the NHS has never been greater, encouraging a variety of organisations to become prime providers of integrated services in the community could offer real opportunities to improve care.

Professor Chris Ham is chief executive of the King’s Fund