In this latest blog, management consultant Scott McKenzie considers NHS in England; money flows, structures and system links & the opportunity this presents for General Practice as providers in Integrated Care.

The focus in the NHS currently lies on implementing the Sustainability and Transformation Partnership Plans (STPs) and converting those to a form of Integrated Care. This could be an Integrated Care System (ICS), or Integrated Care Partnership (ICP). It could be a Multispecialty Community Provider (MCP), which also includes the Primary Care Home, Primary and Acute Care Systems (PACS) and potentially in time Accountable Care Organisations (ACO), where there is an ongoing consultation.

Scott Mckenzie

Independent Management Consultant

A standardised approach

If the aspirations included within STPs and the development of Integrated Care are to happen, it will require that part of the overall STP/Integrated Care solution is the goal of achieving one, high quality and standardised approach without unwarranted variation, becomes the reality within local systems.

Given that every model of Integrated Care is predicated on the registered lists of the General Practices inside their geography, it is imperative that General Practice is engaged before decision are made, rather than consulted once the decisions have been made. For me this requires General Practice to operate with scale and through some form of entity that protects the Practices and vitally allows them to be represented with one voice.

Shift in care?

Inside of the development of ICS, ICP, PACS, MCP and PCH, alongside the implementation of STPs, there is a mindset (rightly or wrongly there is a mindset) that part of the answer lies in the shift in care from in hospital care to out of hospital care. To achieve that it is necessary for a change in the way services are contracted, paid for and then provided. The money has to follow the patient. It cannot be that work is moved in to General Practice but the resources, both people and money, remain in Secondary Care. The transfer of basic services from in to out of hospital care therefore provides an opportunity to create the platform for the larger and more complex system-wide changes envisaged within Integrated Care delivery.

Having said that, without one voice from General Practice in local systems I fear we will see work being dumped on to General Practice who will be expected to pick it up for little or no money. Indeed, I see “baskets of services” being “commissioned” by CCGs, which are normally grossly underfunded. This simply adds more stress to and already overburdened General Practice and puts more of them at risk of failure where the money doesn’t cover the cost of the delivery. I also still see a lot of work being dumped by secondary care, whether intentional or not, it has a big impact on General Practice.

To give a better feel for my argument, my best example of this kind of redesign is a service subcontracted between a Foundation Trust and GP Federation, where the Hospital Consultant delivers the outpatient first appointment in General Practice, working alongside a GP who is delivering the follow up appointments. No patient needs to ever be recalled as we have the consultant onsite working alongside the GP. Any problems can be dealt with on the day.

Redesign overview

To deliver this particular service required the following elements were all brought together:

  1. Everyone with an interest in the redesign was invited to attend three workshops to create the vision, agree the implementation plan and develop the specification. Everyone involved was self-selected, there was no top down command and control of the “sub-committee”.
  2. The skills in the team were enhanced. The two GPs involved took additional qualification and were trained inside the hospital team for 12 months, before being accredited to provide the service.
  3. We focused on redesigning the workforce. The service was originally all consultant led in the hospital, whereas now we have two GPs who deliver all the follow up work, working alongside the hospital team who deliver the first outpatient appointments and ongoing care for those who require their input.
  4. In redesigning the workforce it became possible to redesign the work, primarily as the service could now be provided via a fully integrated team, capable of delivering all the patient care on one site.
  5. A properly funded subcontract was placed that covered all the costs of the service delivery as a minimum.

As the GPs had 12 months training to undertake, there was no pressure on the contracting, meaning the subcontract was ready well in advance of the service commencing. It enabled a new way of working in an integrated team. That process could be used further across other services. The contract covers all the costs in providing the service, exactly as it should.

A properly resourced contract combined with an genuine interest from the GPs who came forward to provide the service that enables the delivery. They created capacity because the work was properly resourced, which is always my experience in working and supporting General Practice, be that a federation, super practice, hub or network of 30k to 50k patients. If the money follows the patient, capacity can and is created. Whereas, if the service had been poorly specified, overly complex or overly bureaucratic, under-funded or worse still unfunded, this would have failed. As a result, what we have is a fully functioning service and a contract that has been renewed.

Nothing to fear

What I see repeatedly in my work is that where people own both the problem and the creation of the solution, you will see change being delivered. Where change often doesn’t work, is when it comes top down, leaving the frontline providers to implement an idea they would never have created had they been engaged right at the start. In that instance, what often happens is that no matter how good the idea people simply don’t/won’t engage and the attempted change fails.

What this redesign reconfirms to me is that there is nothing to fear in engaging everyone affected by the proposed change right at the start and indeed everything to gain. Whilst challenging, it ensures that the vision created is one that has been developed by all those who have a role to play, whatever that role, leading to buy-in and ownership of what they create as a “community for change”, bringing about a critical mass for driving successful change.

There is currently a window of opportunity for those developing Integrated Care Models to engage all providers developing ICS, ICP, PACS and MCP models, including Federation, Super Practice and the Primary Care Home (PCH) sites, to support the implementation of those models, before decisions are made and then imposed. Part of that could be the shift of basic services from in to out of hospital care, with the money following the patient and delivering efficiency back in to the system. The approach is replicable, and creates a win for the NHS, through provision at scale, with the patient in the right place at the right time and with the right healthcare professional, all without unwarranted variation. This in turn creates a clear win for patients, with improved outcomes underpinned by care closer to home within a local General Practice.

I have shared one example, but there are many more from within my work e.g. 24 hour ABPM, 12 lead and 24, 48 and 72 hour ECG, insulin initiation and titration, heavy menstrual bleeding, endometrial assessment with pipelle biopsy, fitting and removal of ring pessaries, uro-gynaecology, including pelvic floor, removal of polyps, frail and elderly and many more. All delivered to specification which include pathways of care, all equipment, drugs, referral points and materials to be used, which prevents unwarranted variation. Payments are tied to delivery and I have seen remarkable outcomes.