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General Practice in Birmingham Part 2

GENERAL PRACTICE IN BIRMINGHAM: PART 2 of 5

The 2016 Annual Report of the Birmingham Local Medical Committee was published in March 2017. It was a year that had seen further massive change and unprecedented challenges for Birmingham GPs and their practice, clearly reflecting common issues across the country. During the year the LMCs’ constituents sought advice and support more than ever before, reflecting the huge and diverse problems now facing general practice and the wider NHS. The report has been divided into a series of five blogs which will be published separately over the next few weeks covering:

SUSTAINABLITY AND TRANSFORMATION PLANS AND MULTI DISCIPLINARY COMMUNITY PARTNERSHIPS

The main plank of NHS England’s national response to the calamitous funding crisis in the NHS and the implementation of its Five Year Forward View was to order every health economy to develop “sustainability and transformation plans” (STPs). The aim of STPs was to produce far-reaching agreement between all local health providers, commissioners and local authorities on the way forward in order to bridge the enormous projected funding gaps and ensure ongoing safe delivery of services. The formation of STPs in Birmingham took place in the context of a massive local authority deficit and service cuts, the fragmentation of commissioning, with West Birmingham being in a different CCG to the soon-to-be merged Birmingham and Solihull commissioning footprint, and also the news of the planned merger of University Hospital Birmingham and Heart of England Foundation Trust. As a result Birmingham was split across two STPs with the Sandwell and West Birmingham CCG practices being in the Black Country STP whilst the Cross City and South Central practices were in the STP footprint covering the new merged Birmingham and Solihull commissioning body. It was stated however that West Birmingham practices would be “associate members” of the Birmingham and Solihull STP.

It soon became clear that STP plans for the transformation of services were being progressed at great pace with, disgracefully, absolutely no engagement with GP providers or their representatives. In order to help rectify this an alliance of the large GP provider groups in the city (super partnerships and federations) was formed in order to help ensure a unified voice for practices across the city to engage and influence the STP process. The LMC was also strongly represented in the GP provider alliance, along with representation on behalf of those practices not formally aligned to a larger grouping.

The GP provider alliance was eventually successful in gaining representation on the various boards and committees created as part of the STP process, and in particular the LMC was represented on the key community care and general practice work streams. However, whilst this representation was most welcome it was quite clear that the principle direction of travel of the Birmingham and Solihull STP was already well-established prior to any opportunity to be significantly influenced by the LMC or GP providers.

In a nutshell the STP’s objective was to plug an estimated £700 million pound funding gap which would arise by 2020/21. This would necessitate a decision not to provide over 400 additional hospital beds which it was believed would otherwise be needed and, needless to say, involved shifting massive amounts of work out of hospital and into the community and general practice.

The intention was to radically transform general practice through working at scale, delivered by a number of hubs servicing geographical populations, rather than being delivered based on practices’ registered lists. As noted above, these aspirations were well-advanced prior to any engagement with GP providers, but with little idea within the STP as to how these changes could actually be delivered.

The LMC robustly and repeatedly made it clear that the entire STP agenda was completely undeliverable without the required substantial additional resources to ensure, first and foremost, general practice sustainability and to massively increase its capacity. Only then could the type of transformation being suggested be properly considered, and of course, only with the full consent and co-operation of general practice. How the STP ambitions will pan out remain to be seen but, by the end of 2016, there was precious little evidence to suggest that the required funding would be forthcoming.

Alongside the STP agenda, NHS England also produced frameworks for its new models for providing integrated care at scale, namely Multi-Specialty Community Partnerships (MCPs) and Primary and Acute Care Systems (PACs). Towards the end of December it then published draft contractual documentation for MCPs. The intention was for general practice to work with community and other organisations to provide extended and integrated general practice and community services potentially also including elements of social care, mental health services and public health. Whilst participation in a MCP would be voluntary for practices, it was quite clear that, due to the appalling crisis affecting the profession, many GPs and practices might be enticed into entering these arrangements if they were seen to offer the only potential solutions to their huge funding, workload and workforce challenges.

The contractual documentation indicated that GP practices could form MCP organisations at three levels, virtual, partially integrated and fully integrated. Joining a fully integrated MCP would require the practice to “suspend” its GMS or PMS contract and, whilst it was suggested that this might be “reactivated” should the practice choose to leave the MCP at a later date, the patients would remain registered with the MCP and would have to actively choose to re-register with the original practice, something which could not be guaranteed. It was evident therefore that any practice choosing to leave its core GMS or PMS contract in order to participate in a fully-integrated MCP was, in effect, permanently forfeiting its existing practice. The LMC issued robust advice to practices about the dangers of going down this path and that they should not in any circumstances be tempted relinquish their core contracts.

Participation in the virtual and partially integrated levels of MCP also entailed currently unquantifiable risks and implications for practices, as these would require them to sign alliance or integration agreements placing burdens on them as providers which were considerably over and above current contractual obligations. Above all it was clear that being part of an MCP at any level would, for the first time, impose responsibility and accountability for staying within wholly inadequate budgets onto GPs and practices as providers rather than holding only indirect responsibility as commissioners. This represented an absolutely fundamental change in the work of and responsibilities of GPs. With so many questions still to be answered the LMC issued initial guidance to practices and also requested further national guidance from the GPC, including legal opinion on the implications of MCP membership. This was still awaited as the year came to a close.

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