Opportunity knocks for GP provider organisations

This article first appeared in the Autumn 2021 issue of AISMA Doctor Newsline, the newsletter of the Association of Independent Specialist Medical Accountants.

The new Health and Care Bill published in the summer sets out how the government plans to reform health services and achieve better integration between health and care in England. Ross Clark and Alison Oliver explore some of its key elements and its implications for general practice.

Background to the Health and Care Bill

This is the first major piece of legislation affecting England’s health and care services since the Health and Social Care Act of 2012, which – amongst other things – reinforced competition as a means of driving up health services’ quality. It also created the NHS Commissioning Board (known as NHS England) and clinical commissioning groups (CCGs) to commission services at local level, now including primary medical services.

Since then the narrative has been focused much more on the importance of integration of health and care services. Some key developments in the intervening period have included:

• The Five Year Forward View (published in 2014) proposed various new models of providing health and care. These models were aimed at achieving better integration of health and care services for patient populations. They included Primary and Acute Care Systems (PACs) and Multispecialty Community Providers (MCPs). For general practice, MCPs offered two models: a fully integrated model (where primary care contracts would be suspended and the funding included with the MCP funding) and partially integrated (where primary care contracts remained outside of, but operated in tandem with, the MCP contract).
• The GP Forward View (2016) promised additional funding for practices to reduce workload, expand workforce and invest in technology and estates, as well as to redesign services to extend GP access for patients.
• NHS Long Term Plan (2019) formally introduced integrated care systems (ICSs) and primary care networks (PCNs). Crucially for general practice, PCNs do not form separate legal entities and so additional services are commissioned as directed enhanced services, forming part of each practice’s primary care contract.
• Investment and Evolution – Five Year Framework for GP Contract Reform (2019) outlined how the GP contract would be reformed to enable implementation of the NHS Long Term Plan. It outlined plans for the introduction of a new PCN contract as a building block of every ICS.

Before 2019, the developments can be seen as efforts to shift the NHS towards more integrated service delivery, with single block contracts covering whole populations. However, the use of directed enhanced services for PCNs under the NHS Long Term Plan saw a return to individual contracting with GPs, albeit with a requirement for the services to be delivered collectively by practices within a PCN.

Overview of the new Bill – system, place and neighbourhood

The new Bill reinforces this direction of travel. In summary, health and social care delivery is organised around:

• Systems – covering a whole ICS with a population of between 1 and 3m and with responsibility for strategy and system-wide planning
• Places – covering a population of between 250,000 and 500,000. Bringing together health, social care and voluntary sectors to redesign local services in cities and towns, likely to be coterminus with local authority boundaries
• Neighbourhoods – covering PCN areas with a typical population of between 30,000 and 50,000, with general practice working with other providers as part of multi-disciplinary teams

Under the Bill, CCGs will be abolished, and every area of England will be covered by an integrated care board (ICB) and an integrated care partnership (ICP), which will together make up the ICS.

Integrated Care Boards (ICBs): ICBs will take over NHS commissioning functions from CCGs and from some parts of NHS England. They will be responsible for commissioning primary care. The boards of ICBs will as a minimum include a chair, a CEO and representatives from NHS providers, general practice and local authorities. ICBs will have flexibility beyond this minimum requirement to determine their own governance arrangements, including the ability to create committees to carry out delegated functions. But NHS England will be responsible for agreeing ICB constitutions and for holding them to account. We expect model constitutions to be published in due course.

Integrated Care Partnerships (ICPs): ICPs will be joint committees formed by the ICB and local authorities together with other local representatives which could include, for example, social care or housing providers. The ICP’s role is to develop a strategy to address health, social care and public health needs in its area and to support partnership working. Crucially however, the ICB is required to ‘have regard’ to this strategy but is not bound to adopt it.

ICSs are currently voluntary partnerships, but the Bill will put them on a statutory footing from April 2022. It is expected this will lead to ICSs being more transparent and accountable.

Other key points of the Bill are:

• The Secretary of State will have increased powers over various matters, including proposals to reconfigure services at the local level
• Collaboration replaces competition as an organising principle. NHS organisations and local authorities will have a duty to collaborate although guidance is still awaited on what these duties will mean in practice.

The House of Commons Health and Social Care Committee (HSCC) has previously recommended that non-statutory providers, which would include practices, PCNs, GP provider organisations and federations, should not be eligible to hold an integrated care provider contract. Putting ICSs on a statutory footing and the Bill’s focus away from competition and towards collaboration hints at the likelihood of single integrated care provider contracts (ICPCs) being awarded at system level.

Key points for general practice for the next few months and beyond:

• General practice will have representation on each ICB, but it is as yet unknown how strong or ‘diluted’ that voice might be as that will depend on its overall composition
• It is unclear what role PCNs will play in the new ICSs beyond the end of the current network contract directed enhanced service. Those services could be brought within the scope of system or place level ICPCs and have a considerable adverse effect on general practice
• Many GP provider organisations/federations already cover the place geography and may be well qualified to take on ICPCs as well as representing their member practices within the ICS. GP provider organisations may need to review their constitutions to ensure that they can fulfil this role. But there is no doubt that this provides an exciting new opportunity for GP provider organisations

It is clearly going to be extremely important over the coming months for GP representatives to closely monitor the detail of how the changes proposed in the Bill will be implemented. They will need to know how those changes will affect primary care and ensure their views are represented at system, place and neighbourhood level.