Model integrating primary care with community and acute services

Some of the challenges facing the NHS can be met by strengthening and expanding primary care services. GPs have recognised this by setting up federations (also known as provider groups or provider networks) and super practices to preserve primary care in their area and to expand the scope of services delivered by them.

The Forward View goes further and suggests that primary care could be strengthened and expanded through integration with secondary care services, in the form of the Primary and Acute Care Systems (PACS) model, and with community services, in the form of the Multispecialty Community Provider (MCP) model.

So how easy is it to integrate services in this way? Most importantly, there is no legal barrier to integration. But as primary care is subject to a different regulatory regime to community and secondary care there are detailed issues that will need to be addressed.

In particular, GPs operate under independent contractor status which, depending on their contracting regime, can offer the benefits of the Minimum Protected Income Guarantee, rent reimbursement and indeterminate contracts. GPs also have long-term interests in their premises.

Individual GP practices, federations, other primary care and community providers and acute, community and mental health Trusts need to understand how they can work together to deliver integration of services.

  • How will core primary care services fit into the new model?
  • Will local GPs integrate with other services through their individual practices (including as a super practice) or their federations?
  • Will GPs agree to move away from ‘independent contractor’ status by transferring their practices to Trusts?
  • Will transferring practices to Trusts allow expansion of primary care service delivery and the upgrading of primary care infrastructure?
  • How will Trusts deal with the long-term liabilities of GPs if they acquire GP practices?
  • What are the benefits to setting up joint ventures between GPs or federations and Trusts as an alternative?

Model integrating health and social care

The Better Care Fund (BCF) aims to address some of the challenges facing the NHS by requiring CCGs and local authorities to commission services in an integrated way. While the NHS and local authorities have been subject to general duties to collaborate with each for some time, NHS England now has the power to direct CCGs to use some of their funding allocation for purposes relating to service integration.

CCGs and local authorities have set up BCF schemes to reduce avoidable admissions to hospital and commission out of hospital care and are now expanding these. CCGs and local authorities may wish to build on the BCF framework to commission integrated services in other ways, for example by commissioning enhanced health in care homes, one of the models suggested by the Forward View.

NHS Trusts and Foundation Trusts need to ensure they engage with CCGs and local authorities developing BCF plans. Separately, they can also set up their own arrangements with local authorities to deliver integrated health and social care services.

Both commissioners and providers can use existing legal powers to integrate services in these ways; these powers are set out in section 75 of the NHS Act 2006 and the arrangements are usually documented in section 75 agreements.

  • Do NHS bodies and local authorities intend to delegate any functions to enable them to exercise both health and social care functions?
  • Are you setting up a pooled fund of mixed health and social care monies?
  • Are you setting up a partnership board to oversee the arrangements and, if so, will it be a joint committee or just a working group?
  • Are you contributing staff, premises, equipment or other assets to the arrangements?
  • What monitoring arrangements do you need to put in place for governance purposes?

Model integrating hospital services across multiple organisations and sites

NHS England’s commissioning intentions indicate a continuing desire to develop consolidated centres of excellence for specialised services where quality and patient volumes are strongly related. The Forward View wants specialised providers to develop networks of services over a geographical region, integrating different organisations and services around patients, using innovations such as prime contracting and/or delegated capitated budgets.

But the Forward View also suggests that this should not be at the expense of the local acute hospital model, whilst recognising that to be viable the NHS payment regime may need to be adjusted, new models of medical staffing may be required and new organisational models will need to be considered.

So there are opportunities for all types of hospital providers under acute care collaborations. Hospitals can consider redesigning local services through a number of different models:

  • Networks of centres of excellence for specialised services
  • Networks of local acute hospitals sharing back office services to standardise processes and deliver efficiencies
  • Specialised Trusts delivering services at local acute hospitals, either for those hospitals or as satellite centres for their own services
  • Leading Trusts sharing their management expertise with local acute hospitals, either on a one-off basis or through the establishment of multi-service hospital chains or foundation-groups (as referred to in the Dalton Review)

There are a number of different organisational forms that can be used to deliver these new care models for hospital services. At the simpler end of the spectrum are contractual joint ventures between partners including ‘buddying’ or management contracts. At the more complex end are corporate joint ventures or mergers or acquisitions. All of these organisational forms can deliver integrated services.

Choosing a new care model – key questions

  • Which model of care for future delivery of hospital services best fits your type of organisation and its strategy?
  • Do you have the skills and capacity to expand hospital services at other sites and / or to provide management expertise for other organisations?
  • What organisational form should you use to set up your new care model for integrating hospital services?
  • Have you considered the competition implications of integrating hospital services, especially with geographically proximate organisations and where there is cross-over in services?
  • How will you be commissioned and funded to deliver expanded hospital services?

What is a hospital chain in the NHS?

Like Accountable Care Organisations, hospital chains are a model which other countries such as Germany and the US are familiar with and which have a track record of success.

The key feature of a hospital chain is centralised strategic leadership for a group of hospitals with each hospital operating with agreed decision-making responsibilities locally, standard operating procedures and centralised back office functions.

The unique features of the NHS mean that international hospital chain models will need adaption here, but there is no reason why they cannot be successful implemented.  Early consideration of developing chains in the NHS has highlighted that key issues to be addressed are:

  • differences between foundation trusts and NHS trusts in a chain
  • merger control under competition law
  • procurement law, especially for management contracts
  • regulation of the hospitals in the chain
  • governance and accountability

Next: Choosing the right organisational form and legal model

Previous: Articulating the rationale for integration

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