NHS England and NHS Improvement ("NHSE/I") have published the Digital-First Primary Care Policy: consultation on patient registration, funding and contracting rules. The document describes NHSE/I's proposals to reform primary care contracting to enable digital-first providers to work better within the system, leading to fairer funding, ensuring patient choice and reducing health inequalities.
What is the problem?
The current primary care contracting system did not envisage digital-first primary care ("DFPC") – a key objective in the NHS Long Term Plan.
The consultation cites:
- A significant increase in out-of-area registrations resulting in CCGs funding care for patients who do not reside in their area.
- Concerns regarding the proportionality of funding given to digital-first providers (by way of the new patient registration premium and the same level of per capita funding as for in-area patients).
- Increasing inequalities in access to DFPC in under-doctored and deprived areas.
What are the proposed solutions?
The consultation is divided into four chapters, each seeking views on a discrete solution. The document concludes that the current out-of-area registration rules need to change and in a way that maintains patient choice. The proposals range from (a) changing the allocations system to enable quarterly recalculation of CCG funding to reflect patient movements to (b) changes to new patient registration payment levels.
The two most significant proposals are:
- When a practice exceeds 1,000-2,000 out-of-area patients, its main contract would automatically be disaggregated, and a new APMS contract would be awarded to the practice by the CCG(s) in which those patients reside.
- From April 2020, digital-first providers could be able to set up practices, most likely in under-doctored areas, through a new APMS contract if they can demonstrate achievement of qualification criteria including a "credible plan" for bringing new GPs into the area.
The focus on creating a clear contracting framework for DFPC is likely to be broadly welcomed by both commissioners and providers. We consider that any solutions need to be mindful of:
- Increased contracting and administrative burdens on commissioners (and practices) whilst attempting to reduce the complexities around funding allocations. Whilst additional APMS contracts for out-of-area patients are unlikely to be particularly onerous and complex, this will create an extra administrative burden on commissioners and practices. Commissioners may hold APMS contracts with practices in a different part of the country, which could be difficult to manage, and, unless there is a change in legislation, those practices would become members of that CCG. An alternative approach to disaggregation is to look at ways in which CCGs can cross-charge each other and agree separately how DFPC will commit to any local service delivery requirements to ensure alignment to emerging Primary Care Networks and integrated care provision.
- Whilst a welcome opportunity to reduce health inequalities, there is a danger of creating a mixed economy of services in different areas of the country and a challenge in how to deliver the NHS Long Term Plan commitments that all patients will have the right to DFPC over the next 5 years.
- Lessons learned from the referenced Equitable Access to Primary Medical Care programme which looked to bring more capacity into "under-doctored" areas and learn from those challenges including the availability of GPs (and other health professionals), the availability of premises solutions and the variable costings, value for money and improvement of patient outcomes/inequalities.
- Streamlining procurement arrangements to secure APMS services is likely to be broadly welcomed but detailed consideration will be needed to ensure balanced qualification criteria to best implement the vision set out in the Long Term Plan. New issues in primary care, such as the ownership of intellectual property will need to be considered carefully.
We are currently speaking to key stake-holders from CCGs, GP practices and digital-first providers to gather views and discuss the key issues. Responses to the consultation close on 23 August 2019 and we will share our response in due course.
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