In July 2016, NHS England published its Multispecialty Community Provider (MCP) emerging care model and contract framework, building on the work that is currently being carried out by MCP vanguards across England.
Unlike the model of integrated primary and acute care systems (PACSs), which is also being explored and which the framework provides reference to, MCPs aim to ‘scale up’ from primary care and are focused on GPs. There is also huge potential at secondary care level as well, points out DAC Beachcroft Partner Charlotte Burnett. “The MCP framework is an inspiring document about what the future could look like. MCPs integrating services as planned have the potential to deliver financial efficiencies as well as improve care for patients,” she says.
The drive towards integration
MCPs are underpinned by a focus on prevention, and on redesigning care with this in mind. Instead of working within the existing healthcare ‘silos’ – primary, community, mental health, social care and acute services – healthcare is organised around population need, supported by a new financial and contractual model. The model also extends to a wide range of services and specialists, including some services which are currently based in hospitals; for instance some outpatient clinics, diagnostics and/or day surgery might all be appropriate to a particular locality.
At the whole population level, the MCP model aims to ‘bend the curve of future healthcare demand’. Within this, it supports a local network of urgent care for people with self-limiting conditions; provides a broader, more joined-up range of services for people with ongoing care needs; and an ‘extensive care’ service for those patients with very high needs and costs.
Importantly, it also fits into the drive from hospital practitioners for much more integration. The Royal College of Physicians’ vision for the ‘future hospital’, outlined in the RCP’s Future Hospital Commission (2013), recommends that medical teams bridge hospital and community settings, with patients only admitted to hospital if their clinical needs require it – including provision for emergency patients to leave hospital on the same day, with medical support provided at home if necessary. MCPs make that possible, by integrating community services with primary care, and bringing in specialists (including community-facing consultants) and generalists (such as district nurses) where this is necessary.
“There’s no major legislation forcing this to happen, and no national timetable; this is clinically led, and driven by commissioners and providers who think it’s good for patients in their areas,” says Burnett. Although there is a degree of flexibility in the way that each area works out its own priorities to determine an MCP, there is definitely an overall framework. The three broad versions which are emerging are ‘virtual’, ‘partially integrated’ and the ‘fully integrated’ MCPs.
In a virtual MCP there is a shared vision and commitment to managing resources together, underpinned by clear arrangements and agreements for how this will work in practice; commissioners and service providers could enter into ‘alliance arrangements’, which ‘overlay’ the traditional commissioning contracts but do not replace them. In the partially integrated MCP, commissioners re-procure all services except for primary medical services (although some locally enhanced primary care services might be included) under a single contract with the requirement to integrate these services with those delivered under GMS, PMS and APMS contracts.
The third vision is of a fully integrated MCP, in which there is a single budget for all primary medical and community-based services. This is the model, as the title suggests, where there is the greatest dissolution of boundaries between existing organisations and the highest level of integration. It allows significant scope for redesigning the local care and workforce roles – but it also involves a lot of change, and a lot of work to make that change happen. Burnett’s view is that there is unlikely to be one size that fits all.
“In some areas where there are existing relationships and provider integration you might find that a virtual MCP develops quickly. In other areas a commissioner could start procurement for a partially or fully integrated MCP in response to a particular issue that they and their local population are facing.”
As NHS England points out, the most critical task in developing an MCP is to get going on care redesign, local hub by local hub. Inevitably, this is not always going to be straightforward. The local needs and the financial case need to be established and the whole process of change needs to be planned, designed and documented by a dedicated team.
It is also necessary to acknowledge from the start that some things will not work out in the way they were originally intended. MCPs need to monitor and evaluate what they are doing – and rapidly address any problems that arise.
In addition, there is the whole issue of culture change. MCPs require collaborative leadership built around a shared local vision, with buy-in from the local community and with local GP practices as well as through federations and CCGs – and a transparent governance structure so that everyone knows how decisions are made. As a number of previous initiatives aimed at integrated working have found, practitioners can find it quite difficult to move out of their usual ways of working (and sometimes their preconceptions about other people’s areas of work) and collaborate on joint projects.
A seamless operation
“If we dissolve those boundaries between multiple organisations, and we get their individuals working more closely in a seamless operation – so that patients aren’t repeatedly having to state the same information to different providers along the patient pathway – that can only work for the patients’ benefit,” Burnett concludes. “It’s that holy grail of patient services closer to home, and more of a focus on prevention and on outcomes, rather than outputs.”