Steve How, Paul Midgley and Oli Hudson, of Wilmington Healthcare, explain how the new GP contract will shape local joined-up systems
The new GP contract, which took effect from April, will stimulate some of the biggest changes in general practice in 15 years in a bid to help the NHS deliver more holistic, joined-up services closer to patients’ homes.
The five-year framework for GP contract reform will support some of the NHS’ key ambitions within the Long Term Plan, which has allocated £4.5 billion of funding for primary medical and community health services by 2023/24.
In particular, the framework will ensure that general practice plays a leading role in the integrated care agenda by putting GPs at the heart of the new local networks that are being formed to help deliver it.
The contract will also provide significant funding for around 20,000 additional healthcare professionals, such as clinical pharmacists and physician associates, who will help to expand the range of services offered by GP practices.
Primary Care Networks
The new framework, which is an agreement between NHS England and the British Medical Association’s General Practitioners Committee (GPC) in England, gives GP practices just under £1 billion funding growth across five years, starting in April this year.
A separate £1.8 billion has been earmarked for Primary Care Networks (PCNs) – groups of practices that collaborate locally, in partnership with community services, social care and other providers of health and care services. This money will come from Directed Enhanced Service (DES) payments, which are an extension of the core GP Contract. To qualify for the payments, GP practices must unite within PCNs by June 2019. The new PCN contract will be introduced from July 1.
PCNs, which each cover 30,000-50,000 people, are the building blocks for Integrated Care Systems (ICSs), which cover a population of one to three million. Fourteen ICSs are already up and running and the NHS wants such systems covering the whole of England by April 2021. Integrated Care Partnerships (ICPs), which cover around 500,000 people, will sit in-between ICSs and PCNs in the new hierarchy.
As well as delivering core GP services, the PCNs will deliver a number of new services that are all linked to Long Term Plan priorities. Five of the services will start by April 2020, namely: structured medication reviews; enhanced health in care homes; anticipatory care (with community services); personalised care; and supporting early cancer diagnosis. The remaining two – cardiovascular disease case-finding and locally agreed action to tackle inequalities – will start by 2021.
Seven work streams, which are part of ICSs’, will be layered on top of the DES-funded services – self-care and planned care, long-term conditions, frailty and end of life care, maternity and family, mental health, on the day care (emergency care) and cancer.
PCN staff and structure
In order to provide an extended range of services, PCNs will need to employ a wider variety of staff than might be feasible within individual GP practices. In fact, it is expected that GPs will eventually be outnumbered by other healthcare professionals who are expected to grow in number by 20,000 over the next five years, funded by the new GP contract DES payments.
The new staff will include additional clinical pharmacists, physician associates, first contact physiotherapists, community paramedics and social prescribing link workers. They will work across practices as part of a ‘network contract’ for the seven new enhanced services and help to free up GPs to focus more on patients with complex needs. The NHS will fund 70% of the cost of most of the new roles with practices paying the rest, as well as fully fund one social prescribing worker per network in year one.
All DES-related and other GPs’ services are likely to fall under the new GP contract and be provided via a PCN. PCNs will focus on service delivery, rather than planning and funding services; while ICPs focus on service development and management.
Each PCN is likely to have a GP as the clinical lead and will be responsible for strategic and clinical leadership to help support change across primary and community health services, as well as overseeing service delivery.
Each service transformation work stream will probably be managed at an ICP level by a programme board. The programme and locality directors are likely to be drawn from CCGs which will have an increasingly strategic commissioning role. The ICP staff will support all the providers ie, acute trusts, community, mental health and PCNs – in delivering the integrated service. How current primary care providers and federations fit into this model is still to be determined but it is likely to be via a subcontract from the PCN, which will be the centre of service delivery outside of a hospital setting.
It will, of course, be important for pharma to follow the progress of PCNs as they take shape across England and to map the new customers that will be emerging – from PCN leads to those in the new reimbursable roles that are being created. Industry also needs to map the new customers who will be working in ICPs and ICSs to help deliver the integrated care agenda.
Pharma products linked to DES-funded services will be a much stronger offer in primary care than in the past. However, to sell them to the new integrated community teams, it is important to understand how these teams are being incentivised and measured.
For example, as part of the NHS’ bid to reduce hospital-based care, all networks will have access to a new ‘shared savings scheme’ tied to reductions in hospital activity, such as accident and emergency attendances, delayed discharge and avoidable outpatient visits.
Many contracts have already been moving away from standard Payment by Results (PbR) to aligned incentive contracts with outcomes metrics, and with PCNs we expect to see increasing risk share between commissioners and providers. This could result in moving specialist nurses into the community and managing patients in specialist virtual clinics instead of outpatients to save money, while ensuring the provider service is not financially compromised.
There will also be changes to the Quality and Outcomes Framework (QOF) to include ‘more clinically appropriate indicators for areas such as diabetes, blood pressure control and cervical screening’. There will also be reviews of heart failure, asthma and mental health. In addition, quality improvement modules will be introduced for prescribing safety and end of life care.
A new PCN dashboard will set out progress on network metrics covering population health, urgent and anticipatory care, prescribing and hospital use. Metrics for the seven new services will be included. The focus on identifying at-risk populations and managing conditions before patients become ill, eg the lifestyle related diabetes prevention programme, is key to enabling the NHS to tackle the rising tide of diseases.
When selling products to PCNs, pharma must think about how its products can deliver wider benefits across the whole care pathway, particularly with regards to keeping people out of hospital where possible – whether that be emergency care or outpatient departments.
Since PCNs will be assessed on their ability to help the NHS deliver on population health objectives, pharma also needs to think beyond the pill and consider the implications of the wider determinants of health, such as diet and fitness. It also needs to define how relevant preventative interventions fit into patient pathways and how it can support the NHS in delivering more proactive care strategies for particular cohorts of patients.
In line with this, it will be increasingly important for pharma to wrap its value proposition around a service that adds real value to the NHS rather than simply providing a product. This could involve anything from electronic devices that monitor drug adherence remotely to segmenting and risk stratifying groups of patients to help the NHS deliver more targeted care strategies.
General practice will play a critical role in delivering integrated care locally and it is under pressure to get PCNs established in the next few months in order to qualify for a slice of the new DES funding. Consequently, changes will be happening quickly.
These changes will see a much wider range of services being delivered outside hospitals and in the community. They will also see GPs working alongside a much broader spectrum of other healthcare professionals to deliver care in line with key Long Term Plan objectives.
Areas that worked as Vanguards, or have already morphed into ICSs, will be first off the blocks in putting the new GP contract into practice. Within about six months, we expect to see a more settled picture across England as pharma’s new customer groups become established in PCNs.
Steve How, Paul Midgley and Oli Hudson are part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com