Digital-First Primary Care policy consultation - summary of key points - closing date for responses 23 August 2019.
The Primary Care strategy and NHS Contracts Group have produced a consultation paper focussing on patient registration, funding and contracting rules.
‘Out of area’ registrations are increasing due to the expansion of the new digital-first primary care models. Challenges include delivering integrated services where patients are registered far from home and planning and budgeting for local services which can be hindered by the interaction between arrangements for charging costs and the flows of funding allocations. Two options to resolve these issues have been put forward, the first being to limit the number of patients who can register as ‘out of area’ and the second preferred option is using the automatic award of new local contracts; a forced disaggregation of the list.
The second option would mean that there would be a pre-determined threshold number of patients who could be registered by a provider ‘out of area’ in any one CCG area. Once the threshold is reached, a new local contract would be awarded to the provider in question. Where small numbers of patients are registered ‘out of area’, it would continue as before but if the number of ‘out of area’ patients hit the threshold, the provision of services would be transferred to a new contract held locally by the CCG. It is estimated that practices should receive between 72p and £2.93 less for an average ‘out of area’ patient than an ‘in area’ patient as they are not required to deliver home visits for ‘out of area’ patients or urgent care during core hours. As the amounts are small, it is anticipated that no change will be made to payment levels at this time, as the amount of time that would be required cannot be justified. Views are sought regarding threshold size and out of area patient payment amount.
CCGs with high numbers of ‘out of area’ registrations become responsible for the health care costs of patient registering with a digital provider in their area. This can be in advance of the additional population being reflected in their funding allocations, causing financial pressure for a CCG hosting a digital–first provider. It is stated that resources for ‘out of area’ patients should flow as soon as practicable to the new CCG that they have moved to and ideally this should happen once per quarter. Where the numbers of ‘out of area’ registrations are low, an adjustment could be made using registration data per capita allocation. This approach may not be sufficient to address concerns that digital–first models will attract patients with lower health needs.
Two further options are submitted to address this issue; practice-specific need indices or need indices of the digital practice itself. The latter will require the digital practice to have a stable profile so that it need indices can be calculated. It will also be considered whether adjustments should be made to only a subset of services such as prescribing costs. An alternative approach would be to use actual costs incurred from previous quarter and apply those but this is not recommended as it could cause greater uncertainty. The risk of small scale registrations of ‘out of area’ patients could drive many burdensome low value financial adjustments inefficient to be disregarded where ‘out of area’ patients falls below a threshold.
A similar adjustment should be made based on registered patient flow and an age gender adjusted capitation payment be made for base line impact. For patients moving during 2019 /20 the process above will be used with a baseline adjustment made for Babylon at Hand. Views are sought in relation to; resources following patients where there are significant movements; definition of significant; threshold for flow of out of area patients adjustment and a capitation based approach.
New patient registration premium
The premium has been reviewed in light of the expansion of digital-first primary care models because of a continuing high number of new patient registrations and a high rate of patient churn. Those registering are more likely to be younger and healthier rather than existing patients with comorbidities and more complex needs. The options considered are as follows are whether the new patient registration should be abolished, retained or kept and a stricter criteria for payment set which is the preferred option.
Views sought include payment of premium and if the patient stays for a set period, and what is the right length of time for the practice to be paid the registration premium.
Harnessing digital-first primary care
A new programme will be introduced in 2019/20 to support ICSs, STPs, CCGs, PCNs and practices develop an integrated digital-first offer that support patients. A new framework will be available for digital suppliers and there is recognition of the need to improve access to GP services in some areas.
With regard to future APMS arrangements, a provider would need to; offer a full primary medical care service; have physical premises; provide services for all cohorts; integrate with other services; cooperate with the relevant PCN; become a member of the CCG and agree to an APMS contract.
In addition, patients must be able to book appointments on line; there must be an evidence-based symptom checker; provision for video consultations; asynchronous consultations; management of repeat prescriptions on line and full and integrated access to GP medical records on line. An APMS contract would be offered on a rolling basis without fixed length. Funding would be based on patient registration with capitated payments using the Carr Hill formula.
It is also discussed whether new opportunities should be created anywhere or restricted to areas that lack GP capacity. If an ‘anywhere’ approach is taken this could lead to an unequal spread of providers, which could lead to instability. It is considered more beneficial to target opportunities in areas of identified need to tackle health inequalities.
Should this occur providers would need a credible plan to bring additional GPs into the area from outside and deliver this additionality as an ongoing contractual requirement. However, there is no standard methodology to identify under-doctored areas. Methods suggested include analysis of weighted patients per GP or consideration of the equitable access to primary care programme. Closed practice lists could determine where opportunities exist. Opinions are requested regarding methodology to identify areas lacking GP capacity.
Physical premises would also need to be agreed with the relevant local commissioner with some face to face services to be set up in a deprived part of the CCG. Providers are to establish services and take steps to ensure that their registered population reflects the wider population they are being asked to serve this would be reflected in the APMS contract. New providers could be set up from April 2020.
Possible commissioning routes include standalone procurement which is thought to be inefficient as it would take between six to nine months or call off exercise which also could be time consuming. The preferred option is to set up new practices in defined circumstances being thought to be more practical and simpler.
Eligibility would include the following; holding a GP contract to deliver essential services for primary medical care, an ability to deliver a digital-first service, to have a credible plan and an ability to meet new IT standards for data security and interoperability.
All providers wishing to take up the opportunity to offer services must go through an assessment process – three possible assessment approaches; single national provider list, CCGs establish a provider list and the preferred approach is for NHS England to run national approvals process for providers with appropriate local input regarding out of hours out of hours extended access provisions, enhanced scheme requirements, compliance with local referral processes and procedures and digital integration requirements.
Further consultation questions regarding new contract holders and under-doctored areas are contained in the link below.