Collaborate, keep control and carry on

Author: Chris Barker, chief executive of the Spirit Health Group.
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Chris Barker, chief executive of the Spirit Health Group (which runs four GP practices in the Midlands), explores how a new generation of Long-Term Partnerships could offer the best opportunity to build a thriving, sustainable general practice – and allow GPs to keep hold of precious GMS contracts benefiting their patients through a local practice approach.

It’s widely believed that General Practice is in crisis. Despite new funding announcements for the formulation of primary care networks, the introduction of the new stake-backed indemnity scheme and indeed promises made within the new GP contract, investment in services fails to keep pace with substantial increases in the GP workload. Furthermore, the profession is haemorrhaging high quality, skilled doctors, and new models of care are changing General Practice - putting already struggling practices at risk of further upheaval. The King’s Fund says that securing the future of General Practice will not be achieved by ‘more of the same’ but requires a ‘willingness to do things differently’. The question is: how? Opportunities to innovate are out there whilst GP’s retain control of their GMS contract and keep their local practice thriving for patients.

One notable contract change in recent years has been the increased use of Alternative Provider Medical Services (APMS) contracts. These contracts, which allow CCGs to commission primary care services from alternate providers for a time-limited period, were originally introduced to plug gaps in provision in ‘under-doctored’ areas, providing greater patient choice and extended access. They’ve become very popular and now appear to be the favoured option as CCGs confront the challenges of the changing GP workforce. But, with many GP surgeries in need of support or seeking to protect themselves against threats in the market from new care models and increased workload due to an ageing population, could the willingness to innovate extend beyond APMS to explore new models for growth that maintain the longevity of existing and, as some would say, precious GMS contracts? We think it can. Moreover, those models need not be restricted to struggling practices but could equally be applied to thriving surgeries looking to flex and scale. It’s time to innovate, offering patients new ways to access care whilst retaining what is good about local GP practices.

Drivers for change

Between 2013 and 2017, 242 new APMS contracts have been signed while not a single GMS contract has been issued. The growth in APMS may have been part of the reason for the shift in the attitudes of many newer GPs. Whereas, historically, new GPs aspired to attain partner status, more recently flexible working has become more attractive. As experienced doctors leave the profession, the next generation – perhaps influenced by the current reality of practice management – are declining opportunities to replace them as partners, so as APMS practices recruit ‘new’ GPs the cycle continues. This is inevitably placing traditional GMS contracts at risk. With struggling practices keen to avoid scenarios where the last remaining partner is saddled with huge liabilities, many are handing back their GMS contracts, leaving few options but APMS tenders. Many CCGs are moving this way.

For those GMS contract holding practices that want to integrate, collaborate or merge with other local practices or their acute trust, we see some development in Multi-speciality Community Provider (MCP) models and Primary and Acute Care Systems (PACS) exist – but what about the GP practice teams for whom that degree of integration simply won’t fit? Or where that level of integration potentially threatens the essence of primary care. What’s out there for practices that want to transform patient care without the need to relinquish control of their lifelong GMS contracts?

Long-Term Partnership or Collaboration Agreement?

One potential option is for practices to enter into a new arrangement (in addition to keeping their GMS Contract) with a commercial organisation. This would establish advantageous Long-Term Partnership structures where the commercial organisation is fully accountable for supporting the GPs in the GMS Contract to spend time with patients - working clinically whilst minimising the administrative burden of General Practice. Practices (and the GP Partners within) maintain the direct holding of their GMS contracts with NHS England and are then supported to ensure they are able to deliver both clinically and commercially as a practice. Transparent terms of engagement and robust governance can protect GP practices from the potential risks of declining income, enabling them to maximise the benefits of a commercial organisation without relinquishing control. This new model may even guarantee practice partnership income.

This new type of Long-Term Partnership arrangement could, for example, see the burden lifted on non-medical functions such as management, administration and business development, with a practice retaining responsibility for clinical leadership and decision-making. This not only allows practices to exploit the commercial expertise of commercial partners with strong track records in innovation and delivering sustainable growth, it also gifts them access to proven technologies and methodologies to help them deliver the highest standards of service for patients.

By leveraging the capabilities of a proven commercial partner, practices can de-risk decisions in crucial areas such as the use of new technology, administration, triage and service design. This will allow GPs to focus on their main priority – treating complex patients. The approach also has the benefit of providing an independent perspective on key issues, helping GPs make balanced decisions with a future view rather than ones influenced by more embedded behaviours and beliefs.

A significant number of GP Practices are owner operators and others have leases in place, or operate under the NHS LIFT system – all creating responsibilities for day to day running of buildings. The Long-Term Partnership model is designed to reduce the stresses of non-clinical work so far as practically possible to allow GPs the option to focus on clinical care, if they so choose. This facilities management is a key component of the non-clinical service offered through the Long-Term Partnership model. It can reduce expenses by providing central organisational functions and employing a specialist provider of primary care back office functions.

The Long-Term Partnership model offers two alternative solutions. Commercial partners can, where desired, take over mortgage liability, freeing up practice partners from significant liabilities. Under this model, any new GPs would not have to buy in to estates and existing partners can exit as desired. Another option is for the commercial partner to accept liability for leases or NHS Lift liabilities, where desired and legally possible, to reduce financial concerns for partners. In some cases, the commercial partner is able to accept liability for the property, debt or estates, which can release income for partners.

Culture of collaboration

The Long-Term Partnership model aligns with recommendations outlined in the GP Five Year Forward View and sits well within new primary care network thinking, both encourage collaboration between GPs and commercial organisations. However, whilst the advantages of collaboration are widely acknowledged, it’s also recognised that GP practices can sometimes lose elements of contractual control and see less benefit when joining collaborations at a later stage. The Long-Term Partnership approach is built on a memorandum of understanding that is established clearly up front – yielding true collaboration through a transparent long-term partnership. Moreover, this scalable model – where additional GP practices can participate in the Long-Term Partnership – enables practices to benefit, within the comfort of their existing GMS contract, from the economies of scale associated with a commercial partner as well as new care models covering a larger patient population.

Driving the future of General Practice

With General Practice facing an ongoing crisis and healthcare commentators urging practices to ‘do things differently’, the Long-Term Partnership or collaboration model present an exciting opportunity for GPs, practices and CCGs to unlock capacity and expand capability. The approach can work with both struggling practices seeking to realise efficiencies and thriving organisations looking for extra headroom to scale for growth. Moreover, in an era where practices are failing and APMS contracts are being utilised in their place, Long-Term Partnerships allow proactive practices to retain their responsibility for clinical decision-making and, crucially, preserve their GMS status. Ultimately, by keeping hold of their ‘in perpetuity’ contracts, practices can maintain the continuity of care and life-long doctor/patient relationships that patients value highly.

Long-Term Partnership models provide a viable and powerful alternative to current trends within the market, one which is extremely palatable to both GPs and practice staff. In a challenging healthcare environment where the cry for innovation has reached fever pitch, Long-Term Partnerships and collaboration might just be the key to helping GPs deliver effective and sustainable primary care services for their patients – without relinquishing control.