Primary care and the new IHO landscape – navigational issues ahead?

The best way to describe the health system landscape over the last twelve to eighteen months, is, arguably, drip, drip, drip….first we had an election, with associated manifesto promises, then the promise of review, then Darzi, then the promise of a plan, then the plan, but no implementation detail, then the promise of detail… which is largely where we are at now, albeit with more detail emerging in small packages  increasingly frequently through announcements, programmes and guidance.

Various elements of a ‘grand plan’ have been revealed including for primary care the new structural and contracting approaches – single neighbourhood providers (SNP) and multi neighbourhood providers (MNP); and in the provider trust world, the big reveals have been the integrated health organisation (IHO) and Advanced Foundation Trust (AFT). A national neighbourhood health implementation programme (NNHIP) hosting 42 pioneers across the country has also been established.

An SNP is a contract to serve populations of approximately 50,000 using PCNs as a springboard and provide enhanced services for groups with similar needs. An MNP is for populations of 250,000 plus people providing care across different neighbourhoods and intended to unlock the advantages of working at scale. This is currently focussed at GP Federation level but the suggestion has been that going forwards there could be an option for trusts to be providers of neighbourhood services. In terms of IHOs, we now understand that an IHO is a contract, as opposed to a new structural form, and is intended to enable an incumbent (expected to be the new AFT) to hold a whole health budget for a local population, joining up care across pathways with costs and benefits accruing in the same place.

Through all of the recent developments, there has been a consistent and unsurprising message, that primary care is a key area for development – the now much-repeated hospital to community slogan (left shift, by any other name?). Few would disagree that this is appropriate. However, the question now, is how practically will primary care work, and do the approaches which have been announced to date, bear any prospect of enabling a solution to the issues identified? For example, key challenges include the need to manage health service demand and enable close working relationships with communities.

Or could they in fact, particularly with the addition of the IHO, muddy the waters further for those active in primary care? With the rate of change and drive for scale, some may argue that primary care (and in particular, general practice) is being set an impossible task and that provider trusts will ultimately be the recipients of the contracts.

It is interesting to note that the original leader of the NNHIP, former GP John Oldham moved on shortly after the pioneers were announced. This was for ‘personal reasons’ but he was also reported to have commented that hospital trusts may not be appropriately experienced to take on the population health role required for an IHO to work. His view was that they would need to embrace a “development process and a change” and the IHO would need to “understand the culture of local authorities and primary care, how population health management is constructed, and the input of public health into that”. Comments like this underline the importance of partners at all levels being in sync and working together to share existing competencies and knowledge if systems are to move forward through IHO structures.

From our perspective in advising both primary care and provider trusts, there are a number of aspects of partnership working and practice which will need to be embedded in IHO contracts and their associated governance going forward to achieve what is required. These will need to embrace all elements of primary care –, recognise that financially the new contracts pose greater immediate financial risk for general practice – and truly enable these voices to be heard and influence decisions being made.

To achieve this, the system needs to consider:

• How it can provide financial support and resource to general practice so that it can create and/or evolve the at-scale organisations needed to host contracts and/or secure the seat at the table from the outset to storm and form the new landscape: creating a level playing field for providers from the outset of the collaboration.
• Not allowing the IHO governance to dilute the voice of primary care at the MNP tier. The 10 Year Health Plan (10YP) affords the opportunity for general practice to lead and drive change at the MNP tier, however, the pause of the MNP contract and drive of IHO development risk stifling this opportunity. It poses a threat that the MNP operations will be subsumed into the IHO and with it the chance for primary care to lead on a neighbourhood health service could be lost.
• Agreeing early principles for the collaboration that provide reassurance to all parties and in particular, general practice, of the intent and scope of the MNP. We are supporting several at-scale primary care organisations in entering into first phase MNP provider collaborations and setting out key partnering principles around perceived “red flags” for general practice (namely the role of the MNP in contract managing general practice).
• Early recognition that these new contracts will replace existing funding streams into general practice and that these funding streams are essential for its survival.

For the system to finally start to realise any left shift which has been mooted for decades there needs to be a strong general practice with equally strong governance.

• Any trialling of new contracts or a transitional approach to “go live” needs to make allowance for the potential loss of guaranteed income in general practice so that we do not unintentionally destabilise the very thing we are trying to develop.

Ruth Griffiths, Partner and Rob McGough, Partner, Hill Dickinson LLP.

PCC is working with Hill Dickinson to support implementation of the 10YP, for example offering workshops on strategic commissioning.  PCC and Hill Dickinson would be delighted to support local areas work through SNP, MNP and IHO options.  Contact enquiries@pcc-cic.org.uk and let us know what would help you.