Stuart Dryden has worked in health for both the NHS and CIC organisations for the best part of the last decade and been employed with Attain for 3½ years. He has worked in roles spanning commissioning, business intelligence, performance, contracting – across secondary care, primary care as well as third sectors. Stuart is drawn to working in ways that can make tangible differences to the way services are contracted and paid (and therefore delivered). He has spent the last 18 months working with NHS Sunderland CCG and their Vanguard programme, helping develop their city-wide aspirations, direction and model in respect to this.
The NHS today is moving towards a new world that is very different from what we currently know, recognise and for some, love. It is shifting in its needs to become a leaner (read:less expensive) commissioner of services, wrapping swathes of services together under various monikers of Multispecialty Community Provider (MCP), Primary and Acute Care Systems (PACS), Accountable Care Organisations (ACO), Accountable Care Systems (ACS) as well as a raft of other more tenuous acronyms that soften the harsh reality of cost and service reconfigurations in the face of the current economic and health and social care gaps.
The need to understand these changes and how these will impact on the ‘day jobs’ of many current commissioner and providers is critical, the current landscape of health commissioning staffed with departments focussed on commissioning, reform, performance, business intelligence, and procurement is about to evolve. It will become a smaller more strategic environment for existing CCGs, whilst providers are needing to gear themselves up to be holders of much larger contracts in both financial value and service provision, potentially with a much wider scope than what they have ever delivered before. In order to adequately deliver services on this sort of scale providers will require a formal contract, as always, that will likely encompass services spanning health and social care as well as primary, secondary and tertiary care and potentially even wider than this (such as, mental health, transport, grant funded charity, etc…). There will be a need to configure itself to likely either be a lead provider of these services handling the bulk of delivery in-house or effectively outsourcing provision and becoming, to a degree, and integrator of services holding a range of subcontracts for services it cannot deliver itself, or is not best placed to deliver itself.
For commissioners this introduces a new level of risk for provision – no longer will they have direct control over providers individually, but they will be part of a chain of risk and assurance. Traditionally this would be managed through the correct utilisation of the NHS standard contract mandated and material sub-contractor details within Schedule 5 Governance. Largely this remains unchanged for the MCP contract but there is a fundamental addition. There will now be the need to ensure that such areas are completed and both all parties have undertaken adequate due diligence to understand the level of provision that is expected from these sub-contractors. This will in turn inform how sub-contract arrangements could potentially destabilise the overall delivery of the wider model if they fail to uphold their contractual obligations with the lead provider (or ACO/S) to deliver.
Through working alongside vanguard sites such as the Sunderland MCP Vanguard that are developing new care models, Attain has seen how these developments could pose some large risks for systems that are essentially pinning hopes on these new models bringing back financial balance and a stronger level of accountability into systems that have maligned over recent years in this respect, whilst also getting providers (old and new) to think and work differently to anything previous.
The opportunities that the utilisation of the MCP contract has are great; it is far reaching and encompasses primary care like the standard contract never has before, putting GPs at the core of the model and having the scope to incorporate registered lists into the MCP itself. It offers an opportunity to learn from other areas nationally and globally in relation to more advanced payment models and offering commissioners the prospect of finally getting to grips with outcomes models rather than ‘input commissioning and management’. It also provides a real juncture to create a much more local and tailored model of contract that hasn’t really been seen in health in recent years.
Clearly with opportunities come risks and potential pitfalls, certainly the use of outcomes is not without controversy, and many have incorrectly attributed the failure of the Cambridgeshire and Peterborough model to the outcomes framework it was upheld for and are therefore risk-averse to the suggestion of moving to a system like this. New care model contracts are also likely to be offered on longer terms such as 10+5 years creating enormous commitments from all system partners and creating overall contract values into many £billions as well as the pressure of assuring these providers can actually deliver contract with this sorts of values. The involvement of general practice potentially poses great risks depending on the level of contractor commitment that specific geographies can realise will be make or break for MCP development in some areas. Beyond the core risk of participation, risks for primary care extend to the basic change from being private business owners to (potentially) employees of the MCP and what this brings in terms of personal and financial needs. There is also the active opportunity to return to the practitioners’ original contractual form (i.e. GMS/PMS) if they chose which poses certain risks alongside the uncertainty that returning to GMS/PMS may not necessarily mean the right to the return of their original list. For commissioning system leaders the need for potential MCP providers to gain primary care commitment is key. For many systems that are working collaboratively across incumbent provision and joint commissioning there remains a looming shadow around the potential for a multi-national provider to court general practice, making personal and financial offers to them that traditional system organisations simply couldn’t compete with and thus creating a system unlike what had been designed and envisaged from the outset.
This all needs to be considered in balance against the design principles and characteristics that are important to commissioners and require protection against what outcomes (both high level and local) are required and to what level of freedom providers need to achieve these whilst maintaining a level of viability, sustainability and in some aspects profit-making to potentially re-invest and further develop services.
The challenge for all NHS and Local Authority colleagues is to understand the levels of these developments in your immediate area and what the real impacts, opportunities and risks for you locally are against the realistic opportunity for success. Attain are delivering this change in a multitude of systems across England, working with system leaders and partners from both commissioner and provider perspectives shaping new care and contracting models and how they will operate once arranged formally. Through the utilisation of scale up/down modelling of subject matter delivery experts, Attain (working with clients) are able to demonstrate effectual whole system change and the shift in focus to prevention and early intervention and achieve the contractual system goals both nationally and locally. This scale up/down model of partnership provision spans across commercial advisory, contracting, procurement, service transformation, business intelligence (and performance) and strategy to work with partners to accomplish real tangible success.