The NHS is planning a complete redesign of the care system – but what impact will the new models have on GP practices? As we await publication of the first contracts, Melanie Thomas of Hall Liddy identifies some of the key issues.
NHS England is pioneering a more joined-up approach to care with the introduction of the MCP (multispecialty community provider) and PACS (integrated primary and acute care systems). By bringing together primary, hospital services, community, mental health and social care, it believes the new models can help relieve the pressure on general practice.
It hopes that GPs will be equally enthusiastic and will happily switch to the new contracts once they are ready. But what will the changes mean for GP practices?
While the impact will depend on how they are implemented in each area, the NHS paper on MCPs published in July and the one on PACS in September outline three broad options. There is the virtual model, where providers keep their traditional contracts; the partially integrated model involving one contract holder who integrates their services with GMS and PMS services; and the fully integrated model, where one contractor holds the budget for a whole population.
This last option is the most radical and would be the most difficult to implement. In our experience, GPs are being asked to engage and co-operate in the major changes proposed without being given sufficient clarity to make informed decisions. The pace of change is fast and the concern is that GPs will be led down a certain route without realising the full impact until it may be too late to turn back.
The fully integrated new models raises many questions for GPs for which there are currently no answers available from commissioners. Here are six of the key issues:
- What would be the employment status of GPs?
Depending on what form the new models take, GPs could be partners in a limited liability partnership (LLP), shareholders in a Community Interest Company (CIC) or limited company, subcontractors or independent contractors, employees or employed within a staff mutual organisation. Where GPs do lose their self-employed status, it could be less advantageous in tax terms. And how would standard salaried contracts fit with GPs’ obligations? How would the new pay structure be agreed – and who would pay for indemnity insurance?
- How much control would they have?
Will GPs be able to choose their own hours, and take on other roles such as lecturing? And how would the changes affect the training of future GPs, given the major role that practices play?
- What would happen to practice staff?
Where GP practices become part of a larger organisation, who would employ the staff? Would the standard TUPE employment rules on transfer of staff apply? As the move would create efficiencies of scale, a redundancy programme may be necessary – but who would manage this and the ongoing HR issues?
- Who would own and run practice premises?
Currently premises are mainly owned by GPs, private landlords or the NHS. Who would own the premises or take over the lease – and look after the ongoing maintenance? If properties were to be transferred, how would valuations be managed and how would cases of negative equity be dealt with? And what would happen to tenants such as pharmacies?
- What about other financial issues?
GPs changing to self-employed status would move from lump sum to monthly tax payments. It could also adversely affect any existing mortgage arrangements. When self-employed status ceases, large tax bills for non-March year ends could be triggered. A more difficult question might be, who would provide working capital if GPs became employees and would the working capital currently held in a GP practice be available for extraction?
Then there are the complex issues relating to VAT and pensions. The NHS says it is liaising with HMRC to ensure service providers can still reclaim VAT, and has agreed with the DoH to allow GMS/PMS contractors to pension subcontracted income in some cases.
- Could GPs revert to the old contracts in the future?
Many GPs are nervous about giving up their existing contracts for good and the NHS is trying to create some formal provision for them to return to their existing GMS/PMS arrangements. However for practices which have undergone major structural changes, it might not be so easy.
The new care models are being held up as the key to a more efficient and sustainable health service, however the devil lies in the detail. Commissioners need to give careful consideration to how best to structure the new contracts to ensure that they live up to the promise.