Last reviewed 19 September 2016
In this feature, Thoreya Swage, Healthcare Consultant, describes the framework under which Multispecialty Community Providers (MCPs) will be operating.
The Five Year Forward View published in October 2014 described new ways in which general practice could operate in the future including working in federations or MCPs.
The 14 Vanguard MCPs have now been running since April 2015 across the country, where groups of practices have been working together to proactively manage patients with complex and continuing needs, using digital technologies as well as developing new skills funded by a delegated health and social care budget. In addition, other MCPs have developed outside of the Vanguard project which are tackling similar issues.
The General Practice Forward View published in April 2016 signalled the development of a new voluntary MCP contract to start in April 2017 to facilitate the integration of primary and community services with wider health services.
In July 2016, NHS England published the Multispecialty Community Provider (MCP) Emerging Care Model and Contract Framework which introduced three versions of the MCP contract and describes the MCP Care Model.
What is the difference between an MCP and an integrated primary and acute care system (PACS)?
Both MCPs and PACS are models of care that aim to improve the physical, mental and social wellbeing of their local populations. Both are based around registered general practice populations and have a responsibility to provide care in the community setting (including primary, community, social care and mental health).
A PACS includes most hospital services within its jurisdiction whereas an MPS may include hospital services such as diagnostics, outpatients and urgent care that extends into the community setting.
The care models also differ in size, for example, an average PACS covers a minimum population of 250,000 (the area usually covered by its local hospital trust) whereas an MCP covers at least 100,000 population.
The MCP Care Model
The MCP Care Model is essential to the delivery of the 44 Sustainability and Transformation Plans (STPs) that have been developed all over England to tackle the health and wellbeing, quality and financial gap that faces the NHS as part of the Five Year Forward View strategy.
In order to develop a better picture of the area it serves, an MCP should have a detailed understanding of the needs of its population and identify where care can be joined up across primary, community, social care and acute services through an analysis of the data including activity and finance. In addition, areas where efficiency savings can be made, for example, through the elimination of duplication of services by different sectors within the MCP area can be identified more easily as the system has a responsibility for the overall budget.
In essence the MCP Care Model should:
take into account the joint strategic needs assessment for the areas covered by the MCP
develop integrated health and care datasets that cover episodes from primary, community, mental health, social and acute care services. An initial step proposed by many MCPs is the use of GP records together with other community services
create risk profiles of the population and estimate potential cost savings of identified interventions
use high-quality data as business support, similar to that provided by Commissioning Support Units to Clinical Commissioning Groups (CCGs)
understand and address variations in health outcomes and costs of the population using the NHS Rightcare method (a follow on from the original Quality, Improvement, Prevention and Productivity (QIPP) programme initiated by the Department of Health in 2009 now run by NHS England and Public Health England), available at www.rightcare.nhs.uk
stratify and segment the population according to risk following the four levels of the MCP Care Model
ensure that the needs of specific subgroups of the population are understood
use data that are joined up across sectors in accordance with the Data Protection Act 1998.
How MCPs should operate
a. Managing future demand
MCPs are required to embrace the challenge of prevention and not to leave this to CCGs and local authorities. This can be best implemented with other partners such as education or housing. The Vanguards are following the six principles of public engagement in order to achieve better working with local populations.
b. Urgent care that is responsive and accessible
Increasingly patients are attending A&E services as access to primary care becomes more challenging. In addition, the range of urgent and emergency care services available can be confusing. Integrating GP services (in-hours, extended hours and out-of-hours), minor injury units, 111, community pharmacies and A&E under an MCP model should simplify the interactions between these services through the sharing of data, care plans and permit the booking of direct appointments. It is expected that all Vanguard MCPs will be working as part of a local urgent care system by April 2017 operating under the following commissioning standards.
A single call is all that is necessary to make an out-of-hours appointment.
Data can be shared between providers.
NHS 111 and out-of-hours services are planned jointly.
The patient summary care record is placed in the clinical hub and other locations.
Patient notes and care plans are shared across providers.
Appointments can be made to GP in-hours services.
Joint governance is operating across all local emergency and urgent care providers.
A clinical hub is operating (virtual or physical) which contains GPs and other healthcare professionals.
Supporting this MCPs are required to provide greater support to patients for self-care including greater use of telecare and health apps, and providing a choice of electronic appointments and prescriptions.
MCPs are encouraged to develop alternatives to face-to-face appointments such as email and telephone consultations as well as video calls.
c. MCP hubs
At the core of the MCP Care Model is the hub. MCPs have a total registered population between 100,000 and 800,000 which are organised into localities or hubs. These hubs are based on registered populations of about 30,000–50,000 which equate to between one to two large GP practices.
A key component of each hub is the integrated community multidisciplinary team (MDT) comprising the primary care team and is supported by other colleagues such as pharmacists, dietitians and physiotherapists, social care workers, wider community teams including district nurses and health visitors plus specialists including consultants. The GP provides the continuity of care through the practice list and the wider teams provide the extended care to support the core primary care services. Specific care co-ordinators help patients and carers navigate through the multiple interactions in the different settings. Through this arrangement people with long-term conditions can be managed more effectively and holistically in the community.
An essential role of the hubs is to identify and manage individuals who are at high risk of unplanned admission to hospital and provide proactive care to patients who require this, as well as facilitate timely discharge from secondary care.
Another major role is to provide enhanced urgent care services so that patients are able to see quickly primary care practitioners such as GPs, nurse prescribers, pharmacists and dentists through a single point of access. This is designed to reduce the need for patients to go to A&E as alternative urgent appointments will be available through the hub.
Some hubs have the potential to widen their service offering by providing diagnostic tests reducing the need for patients to go to hospital; obtaining direct advice from hospital consultants to help GPs manage patients in the community; and developing monitoring units where patients can be observed for up to 12 hours during the working day while tests are being done and treatment plans are determined.
Overall, the hub model enables primary care to work with specialists and community services through three service elements.
Community care — eg maintaining health (such as prevention of falls), medicines administration and monitoring of patients.
Reablement and rehabilitation — supporting discharge and independent living.
Specialist care — managing a specific aspect of a condition in the community, eg wound management by practice and community nurses.
In addition, following the learning from the enhanced health in care home Vanguards, management of older people in this setting will become another facet of the MCP hub model.
The MCP model will also be a test bed for the implementation of integrated personal commissioning.
What is integrated personal commissioning?
Integrated personal commissioning is a personalised approach to the delivery of health and social care through the use of joint health and social care personal budgets. This system is designed for people with complex long-term conditions, severe learning disabilities and mental health needs and wheelchair users.
d. The “extensivist” model
The aim of the “extensivist” model is to provide care centred on the needs of the individual such that all aspects of care including medical, social and psychological are managed in a co-ordinated fashion to enable early and proactive interventions. This model addresses patients with high needs (and high costs) at the top of the MCP Care Model triangle. Clinical responsibility is transferred to the multidisciplinary extensive care service, which is led by an “extensivist” (a GP or consultant), from the patient’s GP. Studies have shown that this model of care results in fewer unplanned hospital admissions and readmissions and shorter lengths of stay.
The MCP contract
Providing integrated care in the community setting begins with GP services working at a greater scale. MCPs start their journey to maturity with the establishment of super practices or GP federations.
What is a GP Federation?
A federation is a group of practices and primary care teams working together, sharing responsibility for developing and delivering high quality, patient focused services for their local communities. Federations generally comprise around 30,000 registered practice populations.
The Multispecialty Community Provider (MCP) Emerging Care Model and Contract Framework describes three versions of MCP contracting.
1. Virtual MCP
This is characterised by an “alliance” of providers working within the scope of the MCP Care Model. This arrangement does not replace current commissioning contracts and could add complexity to the contractual mechanisms.
2. Partially-integrated MCP
This permits commissioners to procure all the services that are under the scope of the MCP except for primary medical services. So the General Medical Services (GMS) contract is retained separately from the MCP contract.
3. Fully integrated MCP
This version allows the MCP to hold the budget for the whole population and covers the total range of primary and community services. This best reflects the way the new care model operates providing the freedom to redesign pathways and workforce roles. Commissioners will be expected to develop service specifications describing the set of services to be delivered by the MCP.
Features of the fully integrated contract include:
a hybrid contract which includes services commissioned through primary medical services (GMS, Personal Medical Services (PMS) and Alternative Personal Medical Services (APMS), and standard NHS contracts)
specific outcomes and standards to be achieved
a 10–15 year term.
A fully integrated MCP will receive a single budget to cover the services to be provided (including performance payments) based on the registered population, together with an estimate of the local unregistered population.
MCPs will be required to form legal entities that are capable of setting up clear governance and accountability arrangements and are capable of bearing financial risk.
All three contracting options are voluntary and NHS England has stated that negotiations should take place locally to determine the best route to follow.
General Practice Forward View, NHS England, Royal College of General Practitioners, Health Education England, April 2016, available at www.england.nhs.uk.
Multispecialty Community Provider (MCP) Emerging Care Model and Contract Framework, NHS England, July 2016, available at www.england.nhs.uk.