Multi-speciality Community Provider Contract in Suffolk Trinity Park – 9 February 2017 Welcome Purpose of this evening is to discuss the options we have to address the unprecedented sustainability challenges now facing primary care. One of these are super-partnerships which we will cover in detail I want to emphasise this is a forum for discussion and debate. Many members have strong views and I will ensure there is plenty of time for discussion – so everyone will be able to speak Federation Board wants to emphasise there is no ‘right answer’. Some practices may conclude super-partnerships are right for them. Others will conclude other options are better We want the meeting to have a practical outcome so not just a talking shop

MCP - Pot of gold or damp squib? Nationally there are four themes to the NHS’ strategy Encouraging prevention and self-management. Many are sceptical about this but it is an opportunity for primary care, particularly as this is to be funded by shifting work from acutes Moving hospitals to fixed budgets and then providers in an area being given a capitated budget to manage. Providers include acutes, primary care, mental health etc. will work in an integrated way. Much less emphasis on competition NHSE has a raft of measures around the workforce e.g. Physicians’ Associates & pharmacists for primary care. Unclear how successful these will be Any additional money is to finance change – otherwise primary care is being told to rely on cost cutting to support practice profitability

What is the problem? First option is to wait and see what happens Argument is that NHSE will eventually realise it has to put more money into primary care which is the most efficient and effective part of the NHS We do know there will be a new voluntary contract in 2017 for networks/practices of 30,000+. Likely to be with more money but include 7 day working Arguments against waiting and seeing is that sustainability issues are hitting now. Its better to do something now than wait until situation gets worse. For the future we only need to look at North Essex which is in a much worse state than Suffolk

Strategic direction for Suffolk West ACO East ICO Note – each partner remains independent – this is not a merger Help people to be more independent for longer, whenever possible Reduce costs of health and social care Create a system that is rewarding to work in Second group of options are around small groups of practices working more closely or even merging: Loose collaborations – like Deben Health Group – 60,000 population around Woodbridge Merger e.g. Two Rivers – 25,000 list created by merger of two Ipswich practices. Similar sized practice in Sudbury Populations of this size are small enough to retain the traditional ethos of partnerships But: To small to influence hospitals and commissioners Without merging its difficult to capture cost savings Merging is time consuming and only half achieve their objectives Being larger on its own does not resolve the sustainability issues e.g. make it more attractive for non-partners

Before and after Original objective when Fed was established was to support the small scale independent contractor model Across country most areas either have or are forming federations. Bottom up initiatives like the OOH co-ops 15 years ago Believe it or not Suffolk Fed is one of the most successful in the country. Recent work has proven 7 day working is feasible and primary care can run whole outpatient departments …but as we have found there are limits to support we can give practices: Fed lacks ‘clout’ e.g. negotiating with acutes Limited impact inside practices because each practice is totally independent I have concluded that federations will not on their own resolve the primary care sustainability issues

ACO/ICO priorities and risks for members Community services – SCH Urgent care – OOH, 111, A&E, admission avoidance West ACO – pain services Risks Impact on workload Personal partner risk/loss of PMS/GMS Hospital run system – PACS model Salaried model is becoming more commonly discussed. Two types: GP owned e.g. Hurley Group which is Claire Gerada’s practice with 4 partners and 80 salaried. It has grown because in East London many partners earn less than salaried GPs. Newcastle Hospitals which has offered to take over practices. Advantages: Reflects desires of salaried GPs. Can focus on day job and bureaucracy done by others Can make and implement decisions covering a large list e.g. Hurley Group has an excellent development programme for young GPs – one we copied for Suffolk Cost savings e.g. centralise certain functions Disadvantages Lose commitment and continuity of partners Our feeling is there is little interest locally. But a partner from the Hurley Group is now Director of Primary Care for NHSE which may demonstrate direction of travel nationally

How do MCPs fit in? First option is to wait and see what happens Argument is that NHSE will eventually realise it has to put more money into primary care which is the most efficient and effective part of the NHS We do know there will be a new voluntary contract in 2017 for networks/practices of 30,000+. Likely to be with more money but include 7 day working Arguments against waiting and seeing is that sustainability issues are hitting now. Its better to do something now than wait until situation gets worse. For the future we only need to look at North Essex which is in a much worse state than Suffolk

30,000-100,000 population – fixed budget What we know about MCPs? 30,000-100,000 population – fixed budget Integrate primary, GP and community services – outpatients? Contract between commissioner and a legal entity – 10-15 years £ = £ per head + 10% performance (QoF & CQUIN) + risk/gain share We have reviewed literature of various think tanks e.g. Kings Fund on strategic options for our practices. We think there are four broad strategic options. Will cover in detail in the following slides

NHSE list of 10 things you need to win an MCP Leadership e.g. locally group, Federation or CCG ‘Engine room to drive and manage transformation Transparent governance and accountability Segment the population with a strategy for each ‘Logic model’ i.e. transformation to outcomes Fit the value proposition with the STP Design and document the redesign Develop a programme of change Learn and adapt quickly Commission and contract Source NHSE As you would expect there are a long list of practical issues around forming a super-partnership What is the new clinical model? This is the exciting bit as there is an opportunity to introduce changes that would not be possible at a practice only level Equalising sessions, holidays etc. Premises particularly tax. It may be worth considering having two types of partnership? John Lewis style with a separate property company for those who want more risk Is their a criteria practices need to meet before joining? Could include proven level of performance, turnover, profitability, internal organisational efficiency, commitment to training and research etc. Profit per partner is likely to be pretty equivalent Dispensing is an issue. Lakeside have retained dispensing by keeping individual PMS/GMs contracts. The other issue is that dispensing practices have higher levels of profitability and it may be difficult to mix 100% dispensing with non-dispensing practices

MCP - considerations for practices No financial windfall – financial & operational risk Possibly need 100,000 Strong and credible GP leadership – with a track record Practices will need to change how they work What legal entity? Need robust organisation, experience, governance and infrastructure to bid As you would expect there are a long list of practical issues around forming a super-partnership What is the new clinical model? This is the exciting bit as there is an opportunity to introduce changes that would not be possible at a practice only level Equalising sessions, holidays etc. Premises particularly tax. It may be worth considering having two types of partnership? John Lewis style with a separate property company for those who want more risk Is their a criteria practices need to meet before joining? Could include proven level of performance, turnover, profitability, internal organisational efficiency, commitment to training and research etc. Profit per partner is likely to be pretty equivalent Dispensing is an issue. Lakeside have retained dispensing by keeping individual PMS/GMs contracts. The other issue is that dispensing practices have higher levels of profitability and it may be difficult to mix 100% dispensing with non-dispensing practices

Proposed way forward for Suffolk Develop the ACO approach – subject to: Genuine change in the way the system works No shift of work without funding Practices have a choice – participate or not Outcome = more sustainable primary care Shift focus of the ‘system’ from secondary care Develop Plan B – MCP approach David Pannell is available to attend either practice or locality meetings to answer questions on the Options for Primary Care paper Moving forward we intend to follow a similar process which formed the Suffolk OOH co-op: If you are interested in pursuing super-partnership further we will organise a meeting in January with a lawyer from Hempsons and BDO who are an accountancy firm. To make this a practical meeting we will ask practices to send their accounts to BDO who will prepare an anonymous comparison of profitability per partner. Meeting would also start to address the type of clinical model We will keep everyone briefed on progress We will write out to all practices following the West meeting