Accountable care organisations need support to get GPs’ pay right

6 October 2017

Mike Simpson

PCC is supporting commissioners as they move towards establishing new provider organisations based on accountable care approaches that may see more GPs employed on salaried contracts.

Our primary care advisers are working with a clinical commissioning group (CCG) to identify GP practice income and expenditure streams. This will help the CCG establish what funding is available to establish a salary range for GPs who opt to move from GMS/PMS contracts to working on a salaried basis for the planned multispecialty community provider (MCP).

The work builds on documents published by NHS England in the summer setting out current thinking on the relationship between GPs, practices and various forms of accountable care organisations (ACOs). The ACO contract currently provides three levels of possible integration for GPs and practices into the new MCP/ACO provider organisation: virtual, partial and full integration.

Mike Simpson, the PCC adviser who is leading the work with the CCG, says: “If GPs are going to work directly for an ACO or MCP then that new organisation needs a set salary framework. The new provider organisation will also have to set out a minimum service specification around the number and length of GP and nurse appointments offered per 1000 patients, amongst other things.

“The commissioner will need to have a consistent approach to access and the range of services a practice offers. Such factors currently affect the profit levels of GP practices working as independent businesses – and the income of GP partners currently working on GMS or PMS contracts.”

For example, Simpson suggests, a single-handed GP with an above average list size who employs a practice manager and one part-time practice nurse would currently enjoy an income  considerably above the average GP income, but potentially be providing a more limited service. Setting aside the GMS or PMS contract and accepting an ACO salary could result in a significant reduction in take-home pay for that notional GP. However, Simpson points out, he or she is also likely to see a dramatic reduction in their own workload, a better work-life balance and less stress – while also improving care and access for patients. better care and access for patients, a better work-life balance and less stress.

“That practice would employ more staff working with an ACO and in many ways they would be offering services and the volume of appointments that practices working as independent businesses should already be providing. The other benefit for the individual GP is that they would lose many of the pressures of running an independent business – such as dealing with all the HR issues.”

Updated documents published by NHS England during the summer set out some of the implications for GPs and practices signing up to be a provider to an accountable care-type organisation – including revamped MCPS.

One of the documents NHS England published in August, GP participation in a multispecialty community provider, says: “The ACO contract requires that where GPs are employed by MCPs they will be offered terms at least as favourable as the BMA salaried GP contract.”

PCC’s work has sought to provide some additional insight into the elements that go into determining the profit – and therefore the potential income – of partners in independent GP practices.

By reviewing the accounts of one practice Simpson identified at least nine potential income streams and 14 potential expenditure streams. He suggests that the practice profit figure could be a reasonable place to start in seeking to establish a reasonable salary for partners.

His work also raised other variables and issues that CCGs and their new provider organisations might have to take into account.

These include:

  • The lack of an agreed definition for what constitutes a clinical session and a full-time GP
  • The absence of agreed minimum staffing levels and the number of appointments that should be offered per 1000 patients
  • The fact that the current basis for profit-sharing might not be linked directly to the number of clinical sessions delivered by each GP
  • The income some GPs earn through owning their own premises.

Where a GP wishes to continue working in their practice as an independent business within the fully-integrated MCP, they could work as a sub-contractor to the MCP, agreeing up-front the terms of this arrangement.

The NHS England document referred to above continues: “Before deciding to procure an ACO contract, commissioners will need to engage with providers to develop the clinical model and consider the contractual models that GPs and others could be interested in. During procurement, GPs will negotiate how much they will work with the MCP to deliver services and whether (and how) they might choose to share in financial incentives.”

In later discussion of the ACO contract, the document says: “The intention is to make MCPs as attractive to GPs as possible and offer them more control and influence over their local health system. GPs will (understandably) only sign up to arrangements that offer them terms and conditions that are right for them.”

The same document says: “As with any business decision there will be commercial opportunities but also risks. Local discussions will need to take account of these issues as GP participation in the model is agreed, including the maintenance of appropriate practice income.”

Referring to the fully integrated model, the paper says: “The CCG would not be able to award a full integrated contract until partners have agreed terms on which they and their employees will work, either within the MCP or as a sub-contractor.”

The documents emphasise that no GP or practice should be forced into one of the contractual models. GPs working to the same MCP could have different contracts.

For support on ACO finances and GP salary frameworks, contact enquiries@pcc-cic.org.uk with “ACO finances” in the subject line.

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