NHS England's PACS Guidance: Bridging the gap between primary and secondary care

Published 10 October 2016

The Guidance

NHS England's "Integrated Primary and Acute Care Systems (PACS) – Describing the care model and the business model" (the PACS Guidance) brings together learning and best practice from the nine PACS vanguards to support and assist emerging PACS models. It is best read alongside NHS England's "The Multi-Specialty Community Provider (MCP) Framework", which we have recently reported on.

Like MCPs, PACS models are population-based accountable care models, with general practice at their core. They are organised around patients’ needs aiming to improve the physical, mental and social health and wellbeing of the local population. Unlike MCPs, they will also include most hospital based care. By aligning the strategy of hospitals with other health and care providers, it offers the potential for a radical new approach to population health.

The PACS Guidance outlines the steps required to set up a PACS model – including the need to develop a new contractual, funding and organisational form – with a focus on shared data, flexible use of workforce and technology and a commitment to partnership working and integration.

Highlights

• Funding will be available to support new sites from 2017/18 where they can clearly show they are planning to implement a PACS or an MCP model. There are plans to increase population coverage of new care models from 8% to 25%. Areas will be invited to submit applications for future MCPs, PACs and acute care collaborations in the autumn.
• PACS contracts can be commissioned by a single CCG or multiple CCGs, NHS England, or a local authority. There is however a clear message that commissioners must work collaboratively (this will include agreements to pool budgets and develop shared governance and decision making processes where possible). The relationship between commissioners and providers will be reconfigured with providers taking on a greater strategic role, managing multiple sub-contractors across the PACS and developing the operating and governance model. 
• NHS England has commenced work with a number of national bodies to address issues that may be seen as traditional barriers to integrated models. This includes agreeing with the Department of Health to amend legislation to allow GMS and PMS contractors to pension subcontracted income subject to certain conditions; working with NHS Resolution (formerly the NHS Litigation Authority) and insurance bodies to ensure clarity around insurance cover for PACS models; and engaging with HMRC about the VAT rules that will apply to PACS arrangements with the aim of maintaining NHS providers' ability to reclaim VAT on contracted-out services.
• PACS will need a new business model to deliver the care model. They will operate as accountable care models; providers will be commissioned, paid and held to account on the basis of shared goals for population health.

The PACS Guidance sets out a number of similarities between MCP models and PACS models, including the three emerging contract forms:

• the ‘virtual’ PACS, where providers (and potentially commissioners) are bound together by an alliance agreement which overlays the traditional contracts held by each provider with commissioners;
• the ‘partially integrated’ PACS, where a contract is awarded for the vast majority of health and care services with a single budget but will exclude primary medical care services; and
• the ‘fully integrated’ PACS, where there is a single contract for all local health and care services and the PACS holds a single whole-population budget.

PACS are expected to grow organically and there is an acknowledgement that full maturity may be achieved over several years; there is no expectation that all sites will immediately move to the fully integrated model.

PACS need to be formal legal entities and capable of bearing financial risk. Following the collapse of the Uniting Care contract, there may be additional levels of commissioner scrutiny to ensure that the provider can bear appropriate risk and demonstrate this throughout the procurement process.

As with an MCP, PACS care models operate at four levels of population need: (1) whole population – prevention and population health management, using person-level and population data to organise care around people's needs; (2) urgent care needs – integrated access and crisis response teams, reducing the need for emergency or unplanned interventions; (3) on-going care needs - enhanced primary and community care with more services in the home and community setting; and (4) highest care needs – coordinated community-based and inpatient care for the management of complex conditions. The distinction between the two models is the wider scope of the PACS model to incorporate hospital services.

CCGs will need to address conflicts of interest. Whilst this is no change to the current position, CCGs may find it difficult to commission a PACS without experiencing significant conflicts of interest. CCGs may need to work with other commissioners to develop solutions and ensure that a fair and transparent process is undertaken.

The Guidance identifies five crucial elements for a successful PACS model: a commitment to partnership working between local providers (including GPs); a data-driven care model; integrated neighbourhood health and care teams working on small population sizes; flexible use of workforce and technology and a new contracting, funding and organisational model that is designed to deliver the population-based care model.

How can we help?

We have been tracking the development of new care models and vanguards since the publication of the Five Year Forward View. Our large and experienced health teams have considerable experience in NHS change and development.

We specialise in integration in the health market. Our clients are made up of vanguards, ambitious new care models and organisations waiting to see how the policy and the market develops.

Whatever stage your PACS or new care model is at, we can provide all the legal and governance support you need to consider scope and implement your plans. 

We want to support you and want to come and talk about your project (free of charge). Please contact us for more information.