How should the Fed approach the MCP (Multi-specialty Community Provider) contract?

Introduction

  • These notes are based on the outline information released so far by NHSE and the BMA commentary paper. More detail is expected this month.
  • MCP is the voluntary contract proposed by NHSE and needs to cover a population of at least 30,000. NHSE notes all the 14 Vanguards MCPs are around 100,000 and comment that it is better to start small and grow. It is unclear if the practices forming the 30,000 patients have to be geographically contiguous.
  • The MCP contract is intended to integrate primary care/general practice and community services around a GP list. The idea is the MCP uses the fixed budget provided to change the way care is delivered, with savings retained within the MCP. It looks as if 7 day GP working is now excluded.
  • The contract would have national requirements, core elements and local requirements and standards. Potentially all services that don’t need to be delivered in a hospital could be included – but to start with there are likely to have limited scope.
  • An MCP will be a contract between a commissioner and a legal entity i.e. the MCP. The MCP could be owned by practices but equally it could be a hospital or Care UK. The MCP may then sub-contract with practices but the MCP contract will not be directly with them. There are three contractual paths:
  1. Virtual – MCP enters an alliance agreement with CCG to manage say LES. This option offers little change from now and set-up time/costs will be a high proportion of the contract.
  2. Partially integrated – single contract for all non-core PMS/GMS services e.g. QoF, LES etc plus community services. The MCP legal entity would then sub-contract with practices (similar to the way North East Essex diabetes works). This is probably the most attractive and interesting option, particularly as GMS/PMS contracts remain as they are now.
  3. Fully integrated – will involve suspending GMS/PMS contract so we do not think there will be take-up of this in Suffolk.
  • The MCP contract sum will be made-up of:
  • Fixed base £ per head (like a PMS/GMS contract rather than payment for activity).
  • Performance element representing around 10% (basically what is currently QoF and CQUINN – which is the incentive scheme for providers excluding PMS/GMS).
  • Risk/gain share on acute activity - likely to focus on acute admissions but we could potentially ask it to start with outpatients.
  • Contracts will last 10-15 years and be procured via tender.
  • NHSE list ten things needed to develop an MCP. Note only the Federation currently can tick these boxes in Suffolk:
  • Leadership e.g. through a locally group, a Federation or CCG.
  • An ‘engine room to drive and manage the local transformation programme’.
  • Transparent governance and accountability arrangements e.g. for decision making, clinical quality and finance.
  • Segment the population and create a strategy for each. The Clinical Models paper published by the Fed started this work.
  • Develop a ‘logic model’ that sets-out how the proposed transformation will lead to the expected outcomes.
  • Establish the value proposition which needs to fit with the STP.
  • Design and document each component of the redesign.
  • Develop a programme of change.
  • Learn and adapt quickly.
  • Commission and contract.
  • Any bid will need to demonstrate the support of each partner in each practice covered by the MCP. Usually this takes the form of a signature but bids which can demonstrate more than this are usually favoured e.g. they have agreed a Letter of Intent.

Discussion points

  • MCPs cut across STPs and CCGs are likely to want influence and interference. However, there is a strong fit between the proposed West ACO and potential West MCPs. IHT’s viewsare unknown.
  • MCPs are unlikely to generate a huge financial windfall for practices (i.e. it is not Fundholding again) but they will be the only new money around and the opportunity to use savings locally.
  • Realistically groups of practices need to have 30-50,000 patients to bid and a plan to get to 100,000 patients is likely to strengthen a bid. With the exception of the single-partnership there are only a limited number of localities in this position.
  • Each MCP will need strong and credible GP leadership. However, there is a shortage of GP leaders..
  • To bid successfully and for the MCP to work effectively, practices and individual GPs will need to change how they work. At a minimum this is likely to include groups of practices in the MCP working together to deliver:
  • On the Day/minors.
  • A GP led domiciliary care team covering team managing care home patients, the frail elderly, housebound and end of life care.

This model is detailed in the West ACO paper. This change will need to be agreed upfront in an MCP bid, however the single-partnership discussion suggests only a limited number of practices are willing to change their clinical model.

  • Contracting:
  • The BMA has already raised concerns about the impact of MCPs on GMS/PMS contracts. We think it very unlikely any Suffolk practice partnership will want to hold an MCP contract directly as they will need to accept financial risk (e.g. in the way the Fed guarantees the over-spend risk on the North East Essex insulin pump budget).
  • Of the three contracting options we do not expect many practices to go for the Fully-Integrated option which requires the giving-up of PMS/GMS.
  • Therefore, practices will either need to form their own legal entities or work through either the Federation or the single-partnership. If forming their own legal entities will need to set-out how the MCP will accept financial risk. One option could be forming joint ventures with hospitals or other third parties, to provide infrastructure and credibility, but they would be junior partners.
  • NHSE is likely to have very tight deadlines if they want to get MCPs up and running for 1 April 2017 and experience suggests they select bids which have a high probability of being successful. In Suffolk, the Fed is the only GP owned legal entity which can demonstrate a robust organisational form with the experience, governance and infrastructure to bid for and manage an MCP.
  • Historically, GP initiatives, such as Fundholding and indeed the formation of the Suffolk Federation, have been divisive. MCPs have a similar potential with the Fed possibly being stuck in the between unwilling/unsuccessful practices and those moving forward. Our ability to work collaboratively with the LMC does not help. One particular issue which needs recognition is the single-partnership is likely to be well placed to become an MCP and will have national support but only currently involves a minority of practices.
  • Potentially our member practices could generate 20 interested MCP groups which would want Fed support, however realistically we cannot support more than two or three bids.