NHS England has published "The Multispecialty Community Provider (MCP) emerging care model and contract framework" (the Framework), which brings together features and lessons learned from the 14 MCP Vanguards into a high-level framework for future MCPs to work from.
The logic of the new care model is to create more efficient, joined-up pathways that focus on preventative (rather than reactive) care, with the intention of improving health, wellbeing and quality of care, whilst also reducing avoidable hospital admissions and elective activity.
The Framework is not intended as a definitive national policy, but a useful guide which provides an insight into inspiring new opportunities for integration and the dissolution of boundaries, building on the vision set out in the Five Year Forward View. It focusses on the drive to transfer specialist care out of hospitals and into the community; bridging the gaps between primary, mental health, social care and community services.
General Practice must be at the heart of the MCP. As the gatekeepers to the NHS engaging with and placing General Practice at the heart of the new care model will be essential for a successful MCP. With the dissolution of traditional boundaries between primary, community and secondary care providers, there are opportunities for how clinicians come together and over time, redesign pathways for the benefit of patients will create the underlying logic of the new care model.
MCPs must be procured in a transparent way, but this does not necessarily mean that procurement will involve multiple bidders. Following engagement and consultation we expect there to be significant work undertaken on the scope of an MCP. This should lead to a call for competition and we expect potential providers to be looking out for these.
In its most integrated form, the MCP holds a single, whole population budget for all the services it provides, including primary medical services. This should support the dissolution of boundaries and delivery of efficiencies. We expect that MCPs will need to sub-contract services to deliver against the contract, at least initially.
NHS England is discussing with DH an amendment to primary care legislation which would create a formal provision for commissioners to agree with GPs a suspension of GMS/PMS contracts for a defined period. Allowing a right to return to GMS/PMS at a defined future point. This should provide GPs, which must be at the heart of the MCP, with the confidence to collaborate and integrate to develop MCPs.
The MCP may start off as a loose coalition, but sooner or later it has to be established on a sound legal footing.
The Framework describes the publication of a new first draft MCP contract by the end of September (a streamlined hybrid of the NHS Standard Contract and a primary medical services contract, with a 10-15 year term).
There are 3 emerging visions of MCP contracting:
- an alliance contract between various providers and the commissioner(s) or 'virtual MCP'. This is the least disruptive of the options but arguably a more complex contractual structure as GPs continue to hold their GMS/PMS contracts
- a “partially integrated” contract. This is a single contract under which the commissioner procures all community services except primary care services. The provider integrates these services with the services under their GMS/PMS contract
- a “fully integrated model” under which the MCP holds a single whole-population budget for the full range of primary medical and community services. This is the most radical option, but gives the MCP the greatest freedom to redesign care
MCPs need to be formal legal entities and capable of bearing financial risk. Following the collapse of the Uniting Care contract, there may be additional levels of commissioner scrutiny to ensure that the provider can bear appropriate risk and demonstrate this throughout the procurement process.
Partially integrated models may consider managing primary medical care differently at a local level. This might include integration agreements overlaying existing GMS/PMS contracts or sub-contracts helping to break down barriers and committing GPs to new ways of working. In areas where there is not yet the confidence to rely on a suspension of GMS/PMS contracts, and a move into a fully integrated model, this will allow confidence to build, in a sound legal structure, whilst creating the care model and driving the patient benefits.
New care models will move the boundary between what is commissioning and what is provision. The commissioner and provider split cannot be removed without a change to legislation. Commissioners must continue to exist and perform their functions. With the development of a single MCP contract for the provision of services traditionally procured from multiple providers, it is predicable that the boundary between what is commissioning and provision may change. For example, future providers may need contracting teams to manage sub-contracts, whereas the need for large teams of contract managers in a CCG may evolve. Much will depend on the MCP contract and where data flows and reporting will sit and the local delivery model.
CCGs will need to address conflicts of interest. Whilst this is no change to the current position, CCGs may find it difficult to commission an MCP without experiencing significant conflicts of interest. CCGs may need to work with other commissioners to develop solutions and ensure that a fair and transparent process is undertaken.
NHS England, NHS Improvement and the CQC are working together to agree the approach to the on-going oversight of MCPs. These organisations regulate and assure commissioners and providers in different ways. The challenge of providing on-going oversight to MCPs, which are unlikely to be uniform nationally and made up of many different variables, is likely to be high. Providers are likely to welcome this news from NHS England.
The Framework lists ten essential jobs in establishing a successful MCP, as well as creating an engine room, design stages and sharing good news stories and lessons learned – there is a focus on the merits of using IT, the importance of information sharing and enhanced signposting across services.
There are also plans to increase population coverage of new care models from 8% to 25%. Areas will be invited to submit applications for future MCPs, PACs and acute care collaborations in the autumn.
Replacement of CQUIN and QOF with new performance framework focusing on outcomes, improved population health and gain/risk share agreements. NHS England will develop draft performance payment arrangements through joint work with six MCP systems.