1. 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

2. 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

3. 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, 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

4. 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

5. 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

6. 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

7. 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, 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

8. 30,000-100,000 population – fixed budget
What we know about MCPs?
30, ,000 population – fixed budget
Integrate primary, GP and community services – outpatients?
Contract between commissioner and a legal entity – 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

9. 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

10. 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

11. 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