Let the mavericks lead primary care service design

General practice is well placed to lead the changes needed in primary care. The registered patient list puts GP surgeries in a unique position to intelligently monitor the overall health of their population and deliver interventions to keep this population healthy and cared for in the community for as long as possible.

Such an approach is arguably more effective where GPs:

• operate at scale – through federations or other network forms;
• in partnerships with other providers, such as community and acute trusts, and social care; and
• engage with these providers in innovative ways, such as collaborating with specialist colleagues to deliver clinics in the community.

There are many areas across the country that are already experimenting along these lines. However, these innovations are localised, dependent on significant commitment from local leaders and require considerable know-how to work around the complexities, inflexibilities and limitations of different funding streams and contracts.

‘In order to provide more care outside of hospital 24/7, GP practices need to collaborate with each other and work closely with other out of hospital services’

Historically GPs chose to remain outside the NHS as independent contractors rather than salaried NHS employees. This independence, however, was largely illusory as the work they did for the NHS was controlled by a tightly defined core contract. The core contract is negotiated nationally between the British Medical Association and the government.

Over time there have been significant renegotiations that have led to an increasing number of GPs operating through partnerships (1966), a greater focus on capitation and financial incentives (1990), a concentration on quality measures and the opportunity to opt out of delivering out of hours services (2004).

• Chris Ham: We have a radical plan for primary care

GPs also have the opportunity to deliver “bolt-on” services through local enhanced service contracts. These changes have led GPs to increasingly work in partnerships (rather than single-handedly) as part of a wider primary healthcare team. There has also been an increase in the number of GPs that are salaried employees of a practice (rather than partners).

However, this silo model does not adequately meet the needs of a population that is ageing and increasingly living with multiple conditions. In order to provide more care outside of hospital 24/7, GP practices need to be able to collaborate with each other and work closely with other out of hospital services.

Innovation in action

An important feature of the general practices across England that are currently innovating, is that they are working locally to find ways to deliver more integrated care that improves quality and better meets the needs of their local population. To do this, GPs are looking across the different funding streams and contracts available, working around and tweaking those that might help them achieve their overall ambitions and stimulate greater collaboration with other practices and providers.

One inner city area is pooling the funding allocated through the quality and outcomes framework across networks of GP practices to encourage shared risk and responsibility. Practices in the networks receive a proportion of the QOF payment upfront, to invest in infrastructure and care delivery, and the remainder is released on the condition that all practices within the network achieve the required targets.

Alternatively, GP practices in one large northern city have signed up to a single local enhanced service contract that includes a jointly developed and shared strategy outlining the expected services and impact at a practice and group level. This strategy is reflected in key performance indicators, and accompanied by variable funding to share overall investment in general practice across the region. The additional investment is dependent on achieving these performance indicators. Again, the intention is to encourage collaboration across practices and improve overall quality of care.

Standing in the way

Although these and other cases demonstrate examples of innovation in action, GPs continue to report challenges associated with a complex and fragmented system of funding and contracting primary care. GPs report dissatisfaction with the core contract, especially regarding workload demands, income pressures, variability in funding and inflexibilities for innovation. Many of these challenges stand in the way of local networks of providers achieving a more integrated provision of care close to people’s homes.

Community providers at a local level are continuing to feel the legacy of significant structural upheavals. The coalition government’s recent reforms created further instability to a sector that was still recovering from the impact of other recent initiatives such as Transforming Community Services. This instability has generated considerable uncertainty and anxiety for GPs and providers, who are wary of investing in integration and models of care that could be susceptible to further structural disruption.

‘The current contractual framework does not create a permissive enough environment to override the inertia or fear of many GPs’

Government reforms also brought a shift and increase in accountabilities at local level. Of particular relevance has been the emergence of NHS England area teams, which will be responsible for local enhanced service contracts (soon to become community based services contracts).

Some area teams reportedly lack a comprehensive understanding of the provision of primary care and can be geographically distant from the population they cover.

For these reasons, some regions were concerned that their ambition to stimulate innovation and collaboration through these contracts could be usurped by their area team’s lack of expertise in managing these new accountabilities.

An increasingly fragmented range of payment mechanisms further exacerbates these challenges. Payments flow into general practice from NHS England, its representative area teams, clinical commissioning groups and local authorities. Different types of contracts then support these payments: block contracts, tariff, locally commissioned service contracts (which are sometimes subcontracted from other providers) or performance payments, such as QOF.

This fragmentation inhibits collaboration to improve quality and lower costs for a population of patients, as individual funding streams continue to reinforce that GP practices work in silos.

Strong position

It is for these reasons that many providers seem unable to take a “leap of faith” that more maverick GPs describe as necessary. The current contractual framework does not directly prohibit innovation and collaboration, but nor does it create a permissive enough environment to override the inertia or fear of many GPs.

Nevertheless, holding the registered list of patients naturally places GPs in a strong position at the centre of a new approach, and that is working alongside colleagues in the community and social care to deliver integrated services 24/7, coordinated with specialists, mental health providers and other forms of care.

The current contractual and funding context is not adequate to support innovative practices to reach their full potential, or for more risk averse GPs to feel supported to begin their journey towards family care networks. To strengthen the role of GPs as providers of care, and to stimulate a more fertile environment for collaboration, funding for general practice should be brought together with other funding streams through a population based capitated contract.

This approach would allow GPs the opportunity to develop an integrated model of care, centred on primary care and delivered in the community.

Rachael Addicott is senior research fellow at the King’s Fund