We updated clients last month about NHS England and NHS Improvement's Digital-First Primary Care Policy: consultation on patient registration, funding and contracting rules. The consultation sets out 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.
Read our response to this consultation below:
Proposal: If a practice exceeds a threshold number (suggested 1,000-2,000) of out-of-area patients from another CCG's area, then its main contract will be disaggregated. The CCG in which those patients live will instead award a separate APMS contract to that practice (a "Satellite Contract"). The aim of this is to enable those patients to be better connected with local primary care networks ("PCNs") and for the relevant CCG to pay directly and immediately for its patients' care.
Our response: We agree that it's important that practices with out-of-area patients are connected to those patients' local health economies including primary care networks. We also accept that, under the current system where each CCG is responsible for its own budget, CCGs should be responsible for paying for services for patients who live in their area.
Where a practice has large numbers of patients from different CCGs, it would hold several Satellite Contracts and with this there are a number of issues that need further consideration:
- If the Satellite Contracts are time-limited APMS contracts, the change in risk profile as between this type of contract and an evergreen GMS contract will need to be managed by commissioners and providers.
- Will breaches of a Satellite Contract impact upon the original contract held by the digital-first provider?
- Will all relevant CCGs that commission either the original contract or the Satellite Contract need to make contract management decisions together and share information?
- The proposals suggest that those providers with a Satellite Contract would become members of the local CCG, which will add to the administrative burden both for commissioners and providers. Is this proportionate, given the relatively low threshold of out-of-area patients being referenced?
- The threshold of 1,000 – 2,000 out-of-area patients seems arbitrary and should perhaps be proportionate to the practice list size or the CCG's population. As we see more CCGs merging, given the NHS Long Term Plan setting out an ambition of 1 CCG per Integrated Care System, this would then increase proportionately. The proposal states that the Satellite Contract would remain in place even if the number of registered patients subsequently fell below the threshold. The consultation cites that the proportion of patients in London returning to their original practice from a digital provider within one year is over 36% – if this trend continues, we could see Satellite Contracts with only hundreds of patients.
- How would digital-first providers be expected to interact with the PCNs in the CCG's locality? It is an early point in the evolution of PCNs, and the proposed approach with Satellite Contracts would effectively mean that the digital-first provider would need to be party to the relevant Network Agreement in order for the PCN DES funding to flow. This would be a matter of negotiation between the local PCN and the digital-first provider, which may prove difficult. An alternative to this would be for the Satellite Contract to set out the relevant "local" obligations, along with how the digital-first provider will interface with PCNs. This would also overcome the issue relating to PCNs being based on a geographical footprint, and the potential for a digital-first provider to hold a Satellite Contract with 1,000 patients living across a CCG's area, covered by several PCNs.
CCG allocations and new patient registration premium
Proposal: Before the above threshold is triggered, it is proposed that there is a more timely (quarterly is suggested) recalculation of CCG funding to reflect patient movements. The consultation also seeks views on postponing the payment of the new patient registration premium.
Our response: We agree that resources should follow the patient in a timely way. However, there is a lot of detail to work through to ascertain the cost of out-of-area patients which may be a significant burden on already-overstretched CCGs. Presumably the threshold for recalculation would be significantly lower than the threshold for awarding a Satellite Contract; but it would need to be high enough to avoid additional unnecessary administration. Presumably for this mechanism to work, this would need to be aligned with reviews of registered patient list numbers.
In terms of postponing the new patient registration premium until the patient has been with a practice for a defined term – safeguards need to be put in place to ensure that practices with new patients requiring additional resource in the first year are not financially disadvantaged.
Harnessing digital-first primary care to cut health inequalities
Proposal: The proposal considers ways in which to award new APMS contracts to digital-first providers in deprived and under-doctored areas. These providers would be required to establish new physical premises from which to provide face-to-face services.
Our response: While the focus on under-doctored and deprived areas is welcome, this needs to reconcile with the NHS Long Term Plan's objective to offer digital-first services to all patients. There is a danger that offering these contracts only in certain areas creates a mixed-economy of service provision across the country and is restrictive on the market. Any proposed national solutions should not be at the expense of local innovation around primary care service delivery.
In terms of the detail of the proposals:
- The requirement to establish physical premises is one that needs some consideration – could this be a room in a pharmacy or community hospital, rather than a designated GP practice?
- What might the core physical offer look like? How might this integrate with other local providers which is presumably one of the intended consequences of this policy direction?
- Would face-to-face services need to be carried out during core hours as is often currently the case?
- The proposed commissioning route for these new APMS contracts is that all approved providers meeting a set of criteria can set up in deprived areas and deliver services to patients who choose to register with them. If the approval process is nationally led by NHS England and the approval criteria set in advance, the potential for providers to suggest new ways of working or innovative service models could be reduced, so the design of the procurement process will need to be looked at carefully.
- There is also a risk that smaller providers based in one locality would not apply to join the national provider list for fear of significant competition from large national providers. As above, new providers would be required to co-operate with established PCNs but this may not always be welcomed by local practices, and effectively, it would be up to those local practices as to whether they wished to work with the digital-first providers at a PCN level.
It is important to balance the opportunity for local service provision with the opportunity for innovation. The proposal considers looking to PCNs as the default provider of primary care services in the locality. While this may help to support local service provision, it risks excluding providers from outside the area who could offer better value and different ways to provide services, perhaps powered by more advanced technology than a PCN has access to.
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