Two years in and we are already starting to see questions emerge as to whether the PCNs that we have are appropriately sized.  But what is the right size for a PCN?

The rapid development of Integrated Care Systems (ICSs) is the main reason for the questioning.  New system leaders understand there is an important role for PCNs, particularly within place-based arrangements, and so inevitably are starting to question whether the arrangement in their particular area is the right one.

The main question these leaders are posing is whether we have too many PCNs.  If the place based population size is around 300,000 and there are (for example) 7 or 8 PCNs, the challenge is whether there are really 7 or 8 Clinical Directors (CDs) ready to be local leaders of the place-based arrangements, and whether the 7 or 8 can really operate effectively together as a unit.  Does it create too many points of contact to make place-based working really effective, due to the number of local relationships it necessitates with the local acute, community, mental health, social care and voluntary sector providers?

The other question it poses is whether the smaller PCNs can create the infrastructure needed to be able to deliver all that is expected of them.  Can they find the HR, payroll, finance, communications, IT, estates, strategy (etc etc) expertise needed to be effective?  And where will PCNs end up – is the expectation really that there will be 7 or 8 limited companies all operating alongside each other?

The questions around PCN size from a practice level are more frequently the other way round.  Practices who are part of larger PCNs are beginning to question whether this is really the right option for them, or whether they should actually be part of a smaller group of practices.

The problem practices experience is that when the population size starts to get up towards 70,000, and the number of practices gets much beyond 3 or 4, then there is always a challenge with engagement at practice level.  There always seem to be one or two “passenger practices” who at best contribute very little, and at worst block and slow down initiatives and any changes the PCN wants to introduce.

What this in turn leads to is the smaller group of more proactive practices starting to question whether they would be better off on their own, particularly as the value of the PCN contract, the value of the Investment and Impact Fund, and the number of staff that can be employed via the Additional Role Reimbursement Scheme is becoming more and more significant each year.

Larger PCNs have also not been helped by the continual “one per PCN” ruling that comes out for any PCN with a population under 100,000, such as mental health practitioners this year, which favours those areas that have opted for a larger number of PCNs with a lower population size.  It is not that surprising, then, that practices looking to maximise the value of the PCN DES are wondering whether what they actually need is a smaller PCN.  I did suggest at the start of the year that this might be the case.

Where does this all leave us?  What is the right size for a PCN?  The important thing to remember is that there will always be a trade-off between engagement and delivery/effectiveness.  Smaller PCNs can build more engagement, larger PCNs can create a better infrastructure to enable delivery.  It is difficult to deliver without engagement, and it is difficult to create the necessary infrastructure without scale.  There is no right answer, no perfect size for a PCN.

What is most important is that practices work in PCNs that work best for them.  If you are small and it is working, don’t bow down to any ICS pressure that comes down the line to get bigger.  If you are large and it is working, keep going as you are.  Changing PCN size and structure is of itself distracting  and challenging, so any planned change would not just have to be sensible, it would have to outweigh all the disbenefits that would come with making such a change.  Most of the time it will be better to understand the weaknesses of your current situation and work to mitigate them, as well to exploit the strengths that you have, rather than change the configuration of the PCN.

There is a big difference between being a GP and being a GP partner.  All of the training to become a GP is designed to ensure you have the clinical skills needed to deliver great patient care.  The training is not designed, however, to provide you with the skills you need to be an effective GP partner.

A partner in a GP practice has overall responsibility for the running of the business of the practice.  The staff who work in the practice rely on the partners to run the business effectively.  If things go wrong, the buck stops with the partners.  It is a big responsibility.

At the same time, it is a huge opportunity.  Uniquely within NHS, GPs as clinicians have the opportunity as partners to run their own businesses in the way they choose to.  They can employ the staff they want, design their own way of doing things, and have their own rules about how things should work.  This freedom is highly unusual (ask any hospital consultant!), and means that GP partners are independent.  They have no line manager, and no one telling them what they have to do and how they have to do it.

Of course, life is never that simple!  Practices have contracts, and partners are responsible for ensuring the practice fulfils the contract it undertakes.  There may not be any line manager, but there are contract managers, CQC inspectors and others who will step in if the practice is not fulfilling its duties.

But the opportunity to choose how things are done, and to shape the culture of the GP practice, are what have drawn many to GP partnership.  I spoke to Dr Liz Phillips about why, after many years as a salaried GP, she chose to become a partner.  You can hear her story here, but for her it was all about the ability to make a difference.  She is loving her new life as a GP partner!

I have worked with a number of colleagues to provide training sessions on partnership for GPs.  It is interesting to me that the reflections are often not that the model of GP partnership needs changing, but as one salaried GP put it, “I left (the session we ran) feeling GPs need to be conversant with politics, finance, and management, so that we make informed decisions about our roles and the services we run for patients.” (you can read her full reflection here).

She is right.  Practices won’t run themselves, and responsibility cannot simply be delegated to a practice manager.  Partners need to be actively engaged in the business of the practice.  And for this GPs need specific tools and skills.

I wrote recently on the content of a training programme for new or potential GP partners that myself and some colleagues are putting together.  I am delighted to say that this week we are formally launching that programme.  For more information about the programme and how to secure your place, simply click here.

There is no doubt that the role of a GP partner is challenging, but it also presents a huge opportunity to make a real difference to people’s lives (both patients and staff).  As with any role, it requires specific skills and understanding, and our aim in this programme is to give new GP partners the tools they need to be successful in the role.

Dr Rachel Morris and myself are setting up a new “Mastermind” programme exclusively for PCN Clinical Directors.  Here is everything you need to know about the programme (and more!).

What is a Mastermind Group?

A Mastermind group is a group of peers that meet to give each other support and advice.  The beauty of a Mastermind group is that it combines brainstorming, education, peer accountability and support in a group setting to sharpen your leadership and personal skills. A Mastermind group helps you and the other Mastermind group members achieve success. Members challenge each other to set strong goals, and more importantly, to accomplish them.

Mastermind group facilitators start and run groups. They help the group to dive deeply into discussions, and work with members to create success — as each member defines it. Facilitators are the secret to thriving mastermind groups, and I am really excited to be working alongside Dr Rachel Morris to facilitate our new Mastermind Group for PCN CDs.

Through a Mastermind group process, first you create a goal, then design a plan to achieve it. The group helps you with creative ideas and wise decisions-making. Then, as you begin to implement your plan, you bring both success stories and problems to the group. Success stories are applauded, and problems are solved through peer brainstorming and collective, creative thinking.

The group requires commitment, confidentiality, willingness to both give and receive advice and ideas, and support each other with total honesty, respect and compassion. Mastermind group members act as catalysts for growth, devil’s advocates and supportive colleagues. This is the essence and value of mastermind groups.

Why is it only for PCN Clinical Directors?

Being a PCN Clinical Director is one of the most challenging roles there is in general practice right now.  And there is precious little support available.  Those most able to provide support to PCN Clinical Directors are other PCN Clinical Directors, because they are the only ones experiencing the same challenges.  By providing a safe space for a small number of PCN Clinical Directors to come together and support each other we are creating a unique opportunity for those who participate to support each other and thrive in their roles as PCN CDs.

Who are the Facilitators?

The group will be facilitated by Dr Rachel Morris and myself.  We will support the group by facilitating the meetings, providing input, expertise and challenge tailored to the individual needs of each of the participant, and making sure everyone gets what they need out of the group.

Why is it called a Mastermind Programme?

The reason it is a Mastermind Programme is because as well as the mastermind group meetings, those on the programme will be part of an exclusive WhatsApp group for participants (for ongoing support and challenge between meetings!), and will have access to Dr Rachel Morris’s fantastic Resilient Team Academy – with all the resources that includes!  You can find more details about the Resilient Team Academy by clicking here.

When does it start and how often will it meet?

The group will meet every 6 weeks on a Thursday lunchtime from 1pm to 3pm.  All the dates are on the website and can be found here.

How much does it cost and how do I join?

The cost is £1995 plus VAT for a year’s membership of the Mastermind Group.  Applications are via a short application form, which you can find here.  There are a maximum of 12 places available for the group so get your form in quickly, and no later than 31^st July 2021.

More Questions?

If you have any further questions, please do not hesitate to contact me.  Email me at ben@ockham.healthcare

Following the publication of the White Paper in February, new guidance has just been published by NHS England outlining the “Design Framework” for the new integrated care systems that are to replace CCGs and bring providers and commissioners together.  What can we learn from the new guidance about what the new integrated care systems will look like, and what does it all mean for general practice?

At the top of an integrated care system(ICS) there will be two bodies: an ICS Partnership and an ICS NHS Body.  The ICS Partnership is essentially the body to bring health and social care (under the remit of the local authorities) together, and has responsibility to develop an “integrated care strategy”.  There is no explicit mention of the need for GPs or PCNs on these bodies.

The second body is the ICS NHS Body.  This will be a statutory NHS organisation which will receive and distribute NHS funding, and will take on all CCG functions and duties, including the commissioning of primary care.  It is explicitly required to “support the expansion of primary care and integrated teams in the community” (p16).

Because the changes are intended to end the commissioner/provider split in the NHS, the ICS NHS Board is described as being a “unitary” Board: it will have a Chair and at leas two other non-executive directors; an executive team of at least a CEO, Finance Director, Medical director and Nurse Director; and will also have at least 3 “partner members” – one from the NHS Trusts/Foundation Trusts, one from the local authorities, and one from general practice.  The partner members, “will be full members of the unitary board, bringing knowledge and a perspective from these sectors, but not acting as delegates of these sectors”(p20).

What does that mean?  Well, it means there will be a GP on the NHS ICS Board, but it is up to the NHS ICS Board to appoint them, and they don’t have to represent the profession.  This in turn means it is highly unlikely there will be any form of election process.  It is up the NHS ICS Board to come up with and agree how it wants to appoint the partner members.

Beyond the ICS NHS Body, there are two other important pieces of the new system architecture.  One is called “place-based partnerships”, and the other “provider collaboratives”.

In my view place-based partnerships are the most important part of the new integrated care systems for general practice.  Each local system has been asked to define its place based partnership arrangements.  A place should have “configuration and catchment areas reflecting meaningful communities and geographies that local people recognise” (p24), but it is up to local areas to define exactly what that means.

Not only that, but it is also up to local systems to agree the membership and form of governance that place-based partnerships should adopt.  “As a minimum these partnerships should involve primary care leadership, local authorities, including Directors of Public health, providers of acute, community and mental health services, and representatives of people who access care and support” (p24).

Here is where it gets interesting.  The NHS ICS Body remains accountable for any resource deployed at place level, but there are different options outlined as to how this accountability could be discharged through place based arrangements.  These range from it being a consultative forum, that informs decisions made by the ICS NHS Body (ie has no power), to it being a committee of the NHS ICS Body with delegated authority to take decisions about the use of ICS NHS Body Resources.  It can even be delegated authority by both the local authority and the ICS NHS Body as a joint committee to make local decisions and allocate resources.

This is key.  Primary care’s influence and ability to shape the delivery and provision of services is realistically going to happen at a place level not at the wider ICS level, and that ability will be determined by how the ICS designs these place based partnerships in the next few months.

There is an interesting note in the guidance on the role of Primary Care Networks (PCNs) in the place based partnerships, “PCNs in a place will want to consider how they could work together to drive improvement through peer support, lead on one another’s behalf on place based service transformation programmes and represent primary care in the place based partnership.” (p27).  Regular readers of this blog will be no stranger to my view that primary care and PCN influence in the new system is predicated on their ability to work effectively together and present a unified voice.  The good news is that the guidance explicitly states, “This work is in addition to their core functions and will need to be resourced by the place-based partnerships”(p27).

The second important new piece of the architecture is provider collaboratives.  From April 2022 NHS trusts are expected to be part of one or more provider collaboratives.  There is a strong expectation in the new system that providers will work together (as opposed to in competition with each other).  They could be paid (by the NHS ICS Body) separately, or via a lead provider arrangement.  There will be far less competition and tendering in future, as it is to be a “tool to use where appropriate, rather than the default expectation” (p30).

The transition to the new system will happen quickly.  The NHS ICS Body Chair and CEO are expected to be in place by the end of September, along with the draft ICS operating model for 22/23.  NHS staff below board level (ie CCG staff) have been given an employment commitment to continuity of terms and conditions, but this does not apply to those in senior/board level roles.

The most important part of all of this for general practice is how the place-based arrangements will work locally.  It is vital that GPs and PCN CDs get involved in these discussions, and do not leave it just to those who are currently involved in the CCG, as they are the ones who will have to make the new system work.  At this stage there is a lot of local flexibility, and there is an opportunity to ensure systems are put in place that support locally-led bottom-up change, but it is an opportunity that won’t last long.

As PCNs enter year 3 of their existence, they are growing in complexity.  Not only is the number of staff employed by the PCN continuing to increase, the expectations and requirements on PCNs is also going up.  The more the PCN becomes like a business in its own right (as opposed to a shared enhanced service across practices), so the importance of the PCN having a financial plan grows.

To date it has been easy enough to monitor the finances based on the individual funding streams associated with the PCN: the ARRS funding (which has pretty tight rules about how it can be claimed); the PCN CD funding (which generally goes to the PCN CD); the extended hours access payment (which generally goes to the practices who have provided it); and the £120 per bed care home premium (which is generally paid according to the beds managed by each practice).  I have not included the network participation payment as it is paid directly to the practices and by and large stays there.  That only really leaves the core £1.50 per head funding, and the PCN development monies (which are handled differently in different parts of the country) that have required any debate as to their allocation.

It won’t be so simple going forward.  This is for a number of reasons.  The first is that many PCNs have been managing the vaccination service which is highly unlikely to have exactly broken even, and so have to decide how any surplus is to be used.

The second is that the PCN CD money has once again been increased to 1 wte for the April to June period.  This creates a significant sum: a 50,000 population PCN will receive just over £26,700 extra for these three months.  Most PCN CDs do not have the capacity to work full time in the role (because of their clinical and practice commitments) so PCNs have to decide how they will make best use of this funding.

The third is the Investment and Impact Fund (IIF).  Not only will PCNs (eventually) receive payment for achievement against last year’s IIF (up to £21,534 for the average PCN), there is a small in year payment available for this year (£5,400 for mapping appointment slot types to national categories by the end of June), as well as the opportunity to earn £40.5k in total by the year end from the indicators announced.  The total IIF earning opportunity is due to rise to over £120k with the addition of the indicators not yet announced but set to commence in October.

The IIF funding has caveats not contained within the core funding and any funding earned from the vaccination service – “a PCN must commit in writing to the commissioner to reinvest any IIF Achievement Payment into additional workforce, additional primary medical services, and/or other areas of investment in a Core Network Practice” PCN DES 10.6.16.  It is the arrival of the IIF funding that means it suddenly becomes more sensible for PCNs to think about the finances in the round, as opposed to in terms of each individual funding stream.

If a PCN combines its core funding, any surplus generated from the vaccination work, the IIF funding, any unallocated PCN CD funding, plus any development monies it has been able to secure, then it can create a funding pot that it has relatively flexible use over.  There are some requirements governing some of these funding sources, but if a PCN can create an overall expenditure plan (i.e. how it wants to use the money it has), it can generally allocate the expenditure items against the different funding sources to ensure it complies with the rules.

So for example if a PCN is looking to reimburse GP time for clinical supervision of ARRS roles, or employ a PCN project manager, it may be better to allocate at least some of this out of the IIF monies rather than the core funding as it meets the IIF requirements and means the PCN then has total freedom for how it uses the remaining funding.

This financial complexity will continue to increase for PCNs moving forward.  The new PCN specifications likely to be introduced in October will have demands that require some sort of funding.  The IIF is due to be worth nearly a quarter of a million pounds to the average PCN by 23/24.  The commissioning of extended access via PCNs from next year will have its own financial (as well as operational!) challenges.

Now is the time for any PCN that has not created a comprehensive financial plan (as opposed to managing each of the PCN finance streams in isolation) to do so.  It is a good habit to create, and one that will reap significant dividends down the line.

Many PCN CDs describe a sense of uncertainty as to what exactly it is they are supposed to be doing in the role, and are concerned as to whether they are meeting expectations.  Often they are plagued by self-doubt, exacerbated each time they hear of another PCN achieving something that they may not have even thought of.

What makes a good PCN Clinical Director?  What is the role really about, and how do you know if you are being effective?

There are three things to understand about the PCN CD role:

The role is about making change happen.  Ultimately what will separate the successful PCN CDs from others will not be how many meetings they attended, how well they understood the PCN DES or the intricacies of the ARRS, or how many WhatsApp groups they were on.  It will be whether they were able to make change happen within their PCN.

But making change happen is not easy.  People do not like change (even the ones that say they do!).  We all gain comfort from our routines and ways of doing things.  Change means stepping out of these and doing things we are unfamiliar and uncomfortable with.  Naturally, we will all resist change.  Even when the new way of working is better, most of us will be reluctant to make the step away from what we are currently doing.  It is human nature.

The PCN CD role is about making sure the changes that are chosen are the right ones, and that those within the PCN make these changes.  Which leads us to the second thing to understand about the PCN CD role.

The role is primarily about people.  Making change is really about people.  It is about building relationships and trust so that when you ask those people to move in a certain direction, they trust you enough to follow.

This is not easy to achieve.  People within a PCN will not do what the PCN CD says, just because they have the title “Clinical Director”.  They need a reason to leave the comfort of where they currently are and what are they currently doing to move in the direction the PCN CD suggests.  An effective PCN CD is one who can make this happen.

The role is not about being popular.  Inevitably, different people within the PCN will want to do different things and to move in different directions.  The PCN CD ultimately has to make the decisions about what to do and where to go.  To be effective they can’t be seen to be favouring one individual or practice or group over others.  While others can seek support from their peers, no one else within the PCN will experience the same set of challenges that the PCN CD faces.

Those seeking popularity should not take on the role.  Not only is it lonely, but managing conflict is inherent within it.  There is always an individual or practice actively blocking any change that you are seeking to introduce.  Where the opposition is not vocal and overt, the leader’s role is often to seek it out and bring it to the surface so that it can be dealt with.  Constantly dealing with conflict makes sustaining positive relationships challenging, as well as being exhausting.

One of the best ways of dealing with this loneliness is to engage with peers who are in the same situation.  Other PCN CDs and primary care leaders are the best source of support, as they are most likely facing a similar set of challenges.

Dr Rachel Morris, GP and host of the You are Not a Frog podcast that focusses on resilience, has established a Resilient Team Academy.  This is an online membership programme for PCN CDs and busy leaders in healthcare that not only provides a community of like-minded colleagues, but provides coaching, productivity and resilience tools to support you in your role, and will help you as you lead and support your practices and team.

I have teamed up with Rachel and we have created a 6 module online course on how to get people and practices to work together across a PCN.  In the course we provide practical advice on what PCN leaders can do to be effective in the role, and how to avoid the common mistakes that are made such as forgetting it is about people, and taking things personally.

Rachel’s Resilient Team Academy only opens a few times a year for new members.  If you want to join you can do so now, but only until Monday 3^rd May.  If you join using this link you can receive a 15% discount on the joining fee, and receive the online course on joint working across practices for free.  It is risk free, because if you change your mind once you have joined, there is a 90 day no quibble money back guarantee.

An effective PCN Clinical Director is one that can make change happen, and can build the relationships needed to achieve this.  It is one of the most challenging jobs there is right now in general practice, and I would strongly recommend that anyone wanting to make a success of this role makes sure they put the support they need in place.  The resilient team academy is a great place to start!

If I were to ask you this question directly, your knee jerk reaction may be, ‘Of course, why else would I work with them?’.  But for many of us, this question raises some uncomfortable truths.

Yes, I may have ‘competency-based trust’ in my colleagues. I know they are capable of practicing safely, have good clinical knowledge and go above and beyond in the care of patients. I also know they are honest, good upstanding citizens and unlikely to nick my car…

But do I really trust that I can speak up, raise difficult issues with them, give them some feedback about the way they behaved in that meeting, challenge a decision they have made about a patient or disagree with something they have done? AND that our relationship will be totally fine afterwards?

Do I know that they always assume I have a good intention towards them? Do I know they will forgive me if I get it wrong or fail at something – even if I should have known better?

This is a different level of trust – vulnerability-based trust.  It is what makes teams work – or not. It is a key ingredient of psychological safety – essentially a climate in which people, ‘are comfortable expressing and being themselves…in which they are comfortable sharing concerns and mistakes without fear of embarrassment and retribution and…they are confident that they can speak up and won’t be humiliated, ignored or blamed.’ Amy Edmondson, The Fearless Organisation.

Unless we have this sort of trust within our teams, we are effectively trying to drive a high-performance car in first gear. The team won’t even be the sum of its parts, and certainly won’t be able to conflict and disagree well, which will lead to artificial harmony, lack of commitment, accountability and ultimately poor results.

One of the major reasons why PCN Directors and other leaders in healthcare struggle to get projects off the ground is an absence of trust in the team between the individuals from the different practices or organisations.

Teams with high levels of trust and good psychological safety have less medical errors, better outcomes, more engaged staff and better performance, so building trust in your team should be a priority for any PCN Director. The problem is that so often we focus on tasks and processes rather than building relationships and trust. Whilst doing a task together is a good way of beginning to build trust (if you do it right!), neglecting to work on the relationships can have dire consequences and can de-rail the whole thing.

So how do you build trust within your teams?

• Really get to know one another. This doesn’t actually take too long. It is possible to make a deep connection in less than a minute if you ask the right questions. Show genuine interest in the other person (and then remember their answers!). Find some ‘uncommon commonality’ (perhaps you have children at the same school, or you’re both origami enthusiasts) or something about their past that shaped them and affected them deeply. Don’t forget to create times where you can have informal interactions (admittedly much harder online – it can be done but you’ll have to plan it more).
• Model vulnerability. Tell people when you’re worried about something, share where you’ve made mistakes and ask for help. Self-disclosure is a powerful way of building a deep connection with people and it shows you trust them if you’re asking for help.
• Assume good intent from others. Assuming that someone has your best interests at heart and that they are saying that thing because they are genuinely concerned, want to learn from mistakes, make things better and that they care about you too is a powerful mindset and the basis of psychological safety. It will allow teams to address all sorts of things in a non-judgemental, open and curious manner. It will help people speak up, recognise problems and challenges before they happen and save a whole load of hassle and heartache.
• Seek first to understand before giving your opinion. Not only will you build trust but you’ll come across as wise too.

Leading teams in healthcare is ultimately about people, not about process. Focus on building trust within the teams in which you work and you’ll reap the rewards several times over.

For more about how to build trust when working across teams in practices and networks, check out the brand new BONUS spotlight course from Ben Gowland and Rachel Morris  ‘How to work together across practices and networks: 6 mistakes leaders in healthcare make and how to avoid them’ available free to you when you join the Resilient Team Academy – a membership for busy leaders providing monthly Deep Dive Masterclasses, ‘done for you’ team resilience building activities, teaching you how to use the Shapes Toolkit coaching and productivity tools with your teams and giving you a likeminded community of peers. Find out more here.

It might not seem like that long since the GP Forward View (GPFV) was published, but at the end of the March we come to the end of the 5 year GPFV period.  Just as a reminder, the headline of the GPFV was an investment of £2.4bn over those 5 years to demonstrate that the challenges in general practice had been heard and understood, and to provide real financial and practical support to the service.  What did the GPFV achieve, and where has it left general practice now?

There are a number of reflections to make about the GPFV:

5 years is too long a time frame.  In 2019, 3 years into the GPFV, the GPFV was effectively superseded by the new 5 year GP contract and the introduction of Primary Care Networks (PCNs).  When announcing funding uplifts a longer timescale works better because the money sounds more, but the reality is things change too much over that time period for it to remain a firm plan.  No one has really spoken about the GPFV for the last 2 years since the new contract was introduced.

It was really about access. While not immediately obvious, what became clear from the GPFV over time was that the real intention of the document was to deliver the government’s agenda of improved access to primary care.  The only significant recurrent additional funding in the GPFV, on top of the contract awards, was the £500m funding, or £6 per head of population, for additional access.  What then happened was the introduction of access stretched the already-thin workforce even further, diverted portfolio and part-time GPs away from core practice, as well as moved funding thought to be for core general practice into alternative providers – the £6 per head never went direct to practices.

In the new contract the primary policy objective is the introduction of primary care networks.  As with access in the GPFV, the real new money follows the policy objective, not the demands of the service.

There was never £2.4bn additional funding.  The GPFV struggled right from the outset with transparency over the funding.  It was very difficult to track and find the money.  Some of us persisted in trying to track it down, and it turned out the extra £2.4bn never really was £2.4bn.  It was less than £1bn.  Headline announcements of large sums of money over 5 year periods are largely an accumulation of inflationary rises to the global sum.  And in the case of the GPFV these were backdated to before the document was even published.

Money in the GPFV came via NHS England to CCGs, sometimes to federations, and eventually to practices.  Multiple pots all had their own application processes.  The money proved difficult to access and was beset by bureaucracy.

In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years. £1.8bn of the £2.8bn comes via the new networks, the rest is primarily in the uplifts to the global sum.  This year the uplift was 2.1%, less than the figures around 3% we were seeing during the GPFV.  But at least this time there is more transparency and the money is embedded in the contract.

5,000 extra GPs was always a myth.  One of the government’s promises when it published the GPFV was to provide an extra 5,000 GPs.  This became a particular source of embarrassment for the government, as not only did it fail to provide the extra GPs but the total number of GPs actually fell.  In 2019 there were 6.2% fewer full time equivalent GPs than in 2015[1].  At that point the old trick of changing the way the numbers are counted was introduced (see here[2]) to try and prevent further embarrassing comparisons.

With the 2019 contract the move was to additional roles to support GPs via the Additional Role Reimbursement Scheme.  How successful this is in supporting practices with the core workload remains to be seen.

It started the journey of delivering care in new ways.  The GPFV promised to support practices to introduce new ways of delivering care, and the Releasing Time for Care programme and the work of people like Robert Varnum on the 10 high impact actions were amongst the most helpful parts of the document.  However, there is no getting away from the fact that it was Covid-19 not the GPFV that has ultimately led to a step change in the way that care is delivered.

But for all its faults, the GPFV did represent a clear change in government policy towards general practice.  Previously, ever since the introduction of the revised GP contract in 2004 which the government felt it had paid too much for, there had been disinvestment in the service over many years.  This had left general practice in a parlous state, and it was only the introduction of the GPFV that really marked the end of this period of austerity.

However, for many this came too late, and the GPFV struggled to stop the exodus of GPs either into retirement or reducing their hours.  As a result the plan was never able to address the core workload and recruitment issues the service faced.

Five years on general practice is starting to feel different, but that is primarily down to the new contract and Covid-19.  The next few years are critical for general practice, particularly in terms of whether it can access the PCN funding to support the delivery of core services and build a sustainable staffing model, and whether it can embed the more helpful changes made during the pandemic. At least with a clear contract now in place the service has a more secure platform than the GPFV ever was to build on.

[1] https://www.bmj.com/content/bmj/369/bmj.m1437.full.pdf

[2] https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services

It is not long ago that at-scale general practice primarily meant the merger of practices into bigger practices, the emergence of super-partnerships and the development of GP federations.  But all that has now changed.

This change has come about because the unit of at-scale general practice has changed.  It is now the Primary Care Network.  The PCN is the unit through which investment is made into general practice, through which delivery is expected, through which the workforce is being developed, and through which general practice will have its voice within integrated care systems.

Historically practices were moving towards at operating at greater scale for three reasons: financial, workforce and influence.  In the last two years since PCNs came into existence it has become abundantly clear the best way for general practice to achieve any of those gains is through PCNs.

As with any change, there are winners and losers.  Those most adversely affected are the large and dispersed super-partnerships, and GP federations.

The large super-partnerships spread out across large geographical areas were built on the establishment of a centralised resource whose cost was prohibitive for small partnerships, but is continually reduced by larger and larger numbers.  These partnerships worked to grow their numbers across the country, and in doing so reduced costs and overall profitability.  But PCNs are based on co-located practices serving specific communities rather than isolated practices joined together by a shared central resource, and so the new PCN environment will not enable this model to thrive.

GP federations were a relatively safe unit of at-scale general practice, that allowed practices to retain their individual identity and ways of working but come together on shared initiatives to secure contracts (such as extended access) and funding (such as for GP Forward View work like care navigation and workflow optimisation).  But with practices now within PCNs, and PCNs receiving any shared initiative funding including extended access, the future for federations as a model for individual practices working together seems very limited indeed.

But the shift of focus of at-scale general practice also creates opportunities.  The biggest opportunity comes for practices working together within a PCN.  The closer those practices can work together, and blur the lines between core practice business and PCN business, potentially to the point of full merger, the greater the opportunity for those practices to use PCNs to stabilise and sustain the core practice model.  If the practices can incorporate the ARRS roles along with the PCN DES requirements into its core business, they have a much greater chance of a sustainable long term future than those that treat all of the PCN investment and work as separate to core business.  We will see this disparity magnified as extended access moves into the jurisdiction of PCNs.

The other main opportunity comes for practices to change the function of their federations.  As I have discussed previously, the limits that PCNs put around at-scale general practice (ongoing and increased individual partner liability, a disparate voice across multiple PCNs within an integrated care system area, a limited ability to support and maximise the value of the new ARRS roles) can all be overcome by PCNs working together within a federation.  While the unit of scale for individual practices is now the PCN, the unit of scale for PCNs could usefully become the federation.

Like it or not PCNs are now established as the primary unit of at-scale general practice. The question for practices to consider is how best to adapt to make the most of the opportunities of this new environment.

A number of PCN Clinical Directors have asked me recently, “What should I be doing now?”.  With so much going on at present, it is no surprise that it is difficult for the leaders of PCNs to remain clear as to exactly where their focus should be.  Just because of the volume of things that are happening, now is a good time for a PCN stocktake.

Investing some time now in a stocktake will help provide a clear sense of direction for the PCN, and help create a renewed sense of focus for the months ahead.

But what should the stocktake cover?  Here are my suggested 10 areas for review:

1. Member practice engagement. The number one priority for any PCN is its members, because without unity and a sense of collectivism it is very difficult for anything else to be achieved.  It is easy when the agenda gets busy for this to fall to the bottom of the list, but engagement is an ongoing process and it is important PCN leaders do not let it slip.  Within this (of course) is how the PCN has (and plans to) support member practices with covid, flu vaccinations, and (potentially) covid vaccinations.

2. PCN vision/purpose. It is never too late for a PCN to work on what it is trying to achieve and what it wants to deliver for its members and the population it serves.  Member practice engagement is much easier to maintain when everyone is agreed on the overall direction of travel.  Even if you did this a year or more ago, it is important to keep it under review to maintain alignment across the PCN.

3. New Roles. PCNs submitted their recruitment plans for this year back in August, so now is a good time to review progress made against that plan.  It is also important to review how well the new roles that have started are working, and what can be done to both help them become more effective and maintain a focus on retention.

4. PCN DES specification delivery. We are now over a month into the delivery of three new specifications (enhanced health in care homes, early cancer diagnosis, and structured medication reviews).  CCGs seem to vary in the closeness with which they are monitoring PCN performance against these specifications, but better for PCNs to be on the front foot, understand how they are doing, and make any change that are needed themselves.

5. Social Prescribing Service. It is also a requirement of the PCN DES that each PCN provides a social prescribing service to their patients.  According to the Investment and Impact fund (see below) a PCN needs to offer appointments for up to 0.8% of its PCN population between October and March, so for a 50,000 population PCN that is 400 appointments (15-20 appointments per week, depending on whether or not you have started yet).  Is your PCN’s social prescribing service up and running and how many appointments per week is it offering?

6. Investment and Impact Fund (IIF). An ‘average’ PCN can earn up to £21,534 in this year’s IIF (for my blog explaining how it works click here).  In the current absence of any national reporting on PCN performance against the IIF, it is worth at least keeping back of the envelope workings out on where you think you are, so that it doesn’t come as any huge surprise when the dashboard finally appears.

7. Local projects. It is all very well making sure the PCN has done everything that is asked of it in the PCN DES, but to thrive and make a difference locally a PCN needs to undertake at least one project of its own.  Tracking the performance of your own projects is probably more important for the PCN than performance against national directed initiatives.

8. Local relationships. We are still in the start up period for PCNs, and crucial for future and ongoing success are the relationships a PCN has in place with its local health and social care partners.  Are there individuals in the community trust, acute trust and mental health trust the PCN can contact to sort out issues or take new initiatives forward?  Are relationships in place with the local voluntary sector to enable the nascent PCN social prescribing service to thrive?  Is the PCN working well with the other PCNs in the area?

9. Preparation for extended access. Looming large on the horizon is the transfer of responsibility from CCGs to PCNs for extended access form April next year.  We are still awaiting guidance on the details of this and what this is going to look like in practice, but a PCN would be wise to at least have started working through what it wants the service to look like, and any major changes (e.g. locations etc) it wants, so that when the guidance does finally land the PCN is in position to move quickly and not lose out on the opportunity simply because the timescales are (inevitably) tight.

10. Preparation for next year’s PCN DES specifications. We have also had a pretty good preview of at least some of the outstanding specifications that are on the way, in particular anticipatory care and personalised care which were published in draft last year before they were dropped from this year’s requirements.  A PCN would do well to plan how it intends to meet the requirements of the new service specifications, so that it can make sure it has the staff and resources in place to deliver it when the time comes.

NHS England published a set of guidance last week in relation to the PCN DES.  One specific piece of guidance was detail on how the new Investment and Impact Fund (IIF) is going to work.

The IIF has the feel of one of those initiatives that probably started out as a good idea, but has been watered down so much in the making of it a reality that its impact is likely to be minimal.

For a start, the sums we are talking about pale into insignificance when compared to some of the other funds on offer to PCNs.  An “average” PCN can earn a maximum of £21,534 in this year’s IIF.  Compare that with the c£350,000 (£7.131 per weighted patient (pwp)) the average PCN has received through the Additional Role Reimbursement Scheme, or even the £75,000 (£1.50 pwp) core PCN funding.  These sums require very little effort from the PCN.

PCNs have already received  c£13,500 (£0.27 per weighted patient) for the six months up to the end of September as a Covid “support payment” for the PCN.  The question, then, is whether the £21,534 available between October 1^st and March 31^st is going to be sufficient to entice PCNs into action, particularly in the context of everything else that is going on.

It depends to some extent on how achievable the targets are.  The scheme is designed like a QOF scheme, but at a PCN rather than practice level.  There are 194 IIF “points” available, each worth £111 each (adjusted for list size and prevalence).  These points are divided across 6 indicators.  For each indicator there are limits outside of which practices either earn zero or the maximum, with a sliding scale applied in between:

It will be hard for any individual practice to achieve the 75% flu vaccination target, let alone 77%.  It will be even more difficult for a whole PCN to achieve it. A non-guaranteed incentive payment of less than £8,000 is not going to change behaviour.  PCNs may well work very hard to achieve as high a vaccination coverage as possible for their local population, but it will be because they want to protect their local population, not because of the IIF.

Even if a PCN does examine the scheme and thinks the rewards could be worth the effort, there are further barriers to overcome.  To earn any IIF funding, a PCN must first “commit in writing to the commissioner that it will reinvest the total achievement payment into additional workforce and/or primary medical services” (2.15).

I find this astonishing.  The IIF funding is not recurrent (it has to be re-earnt each year) but the cost of any additional staff or service delivery is, so how is this supposed to work as an incentive? Equally, if a PCN invests in extra resources to achieve these targets it does not seem as if they can refund their own outlay with any money earned.

We will have to wait and see how these restrictions are applied in practice (e.g. whether any earned IIF funding can be applied retrospectively, whether it can be used to fund on-costs of additional staff not covered by ARRS funds etc).  Hopefully common sense will prevail.  Either way, it seems that either the policy should be to create incentives and allow PCNs the freedom to innovate to achieve them, and the freedom to use those incentives as it sees fit, or it should abandon any notion of payment for performance (which is what this scheme at its heart is) and stick with fixed payments for expected deliverables.  As it stands, this scheme neither promotes investment nor looks like it will have much impact.

We are just over a year from the formation of PCNs and, despite the pandemic, their importance and influence is growing.  Could this incarnation of general practice be the one that finally starts to shape the NHS around the needs of local populations?

The voice of general practice has long been sought after.  Right back from the days of GP fundholding, different regimes have tried different ways to enable general practice, the “gatekeepers” of the NHS, to have a bigger say in how the service is organised.

It would seem the main problem, however, is that this has been done throughout any extremely long NHS experiment with the purchaser provider split.  Each attempt so far (fundholding, primary care groups, primary care trusts, practice based commissioning and clinical commissioning groups) has been hampered by the inability of any of these incarnations (or indeed any form of purchasing) to make its mark on the shape of healthcare provision.

As the purchasing model is finally put out of its misery, and CCGs simultaneously reduce in number and influence, the new order is starting to take shape.  Centre stage are Primary Care Networks.

The NHS already knows that merging organisations makes no difference.  Integration is not about the merger of providers.  We used to have merged community and acute providers.   Back then the argument was that resources were being stripped from community services to fund hospital services.  What was needed was to make community services organisations independent in their own right.  We have just come back full circle.

Merging or not merging organisations is not what integration is about.  Integration is about doing things differently.  About working in different ways to change the experience and outcomes for local people.  The only chance integration, and integrated care systems, has of making this difference is at the level of the Primary Care Network.

This is really important.  Integrated care systems and integrated care partnerships are dependent on PCNs to be successful.

PCNs may only be just over one year old, but we already have groups of practices almost universally working together to provide care for their local populations.  The work to deliver enhanced care into care homes, and to deliver a social prescribing service, has already begun.  Practices are building relationships with voluntary organisations, local authorities, and care and nursing homes in ways not seen before.

We are less than one month away from PCNs finding ways to deliver structured medication reviews to those who need it most, and to support early cancer diagnosis.  With each new service we will see new relationships form, new ways of delivery develop, and new benefits for patients and local people result.

PCNs are not purely conceptual (the problem with many of the purchasing constructs).  An army of new staff who will actively deliver care are currently being recruited.  PCNs up and down the land are building teams of pharmacists, physiotherapists, physician associates and more.  About 10,000 new staff are being put in place this year to provide the energy and impetus to make this work.  Thousands more are to follow next year, and the year after, and the year after that.

PCNs worry about their voice at the “top table” of integrated care.  But the reality is the power sits with them, because they are the ones who can effect real change.  This power will only grow, as their resources grow and they deliver more.  This really could be the opportunity for general practice to finally make the difference it has been seeking to make for so long.

We are getting into the weeds a little bit this week, as we consider what action PCNs can take to ensure they are represented effectively at system meetings.

Regular readers of this blog will know that we have established two important principles when it comes to PCNs attending the wide range of system meetings that they are currently being invited to.  The first is to prioritise local PCN delivery over attendance at these meetings.  The second is that finding effective representation is difficult.

The way to think about this is not to consider first who should represent the PCN, but instead to start by considering how to create the representation the PCN needs.

One of the actions very few of us take (but is really important) is to determine what outcome we want from a meeting before we attend.  Why are we going?  If we are clear what outcome we want from a meeting we can in turn be clear with others who attend for us the outcome we are asking them to achieve.

A set of outcomes our PCN might be looking for in attending a system meeting might be:

• To increase the resources and opportunities coming to the PCN and its member practices
• To enable the appropriate shift of work (and resources) from secondary to primary care
• To accelerate the alignment of community services with the PCN
• To raise the reputation of PCNs and build confidence that they are an effective delivery vehicle

Whatever they are, they need to be ones appropriate for the meeting and for your PCN.  Of course, if your PCN has already taken the time to be clear about its purpose, then the outcomes may well be a version of the those stated in the purpose of the PCN.  Equally, if when you think about a meeting you cannot come up with any outcome you want to achieve by attending, that is probably a sign that you don’t need to go!

The reality is that all of us get invited to meetings when we are not clear what the meeting is or why we are needed.  For the time-poor PCN CD it is far better to spend time seeking clarity on exactly why attendance is required and the outcomes that attendance is seeking to achieve, as opposed to turning up and hoping that clarity will come during the meeting itself (it rarely does).

When we are clear on why we are attending a meeting, the question of representation becomes much easier to handle.  If you can be clear with your representative on the outcomes you are seeking to achieve, they can be much more confident in representing you in the meeting.  This will apply to a non-CD attending for the PCN, or for the CD of another PCN representing your PCN as well.

You can even go as far as being clear what they can or cant agree on your behalf.  For example, anything in line with the outcomes can be agreed, but anything that commits the PCN to additional work has to come back to the PCN for a discussion.  It is perfectly reasonable for a representative to gain rapid agreement after a meeting from those not present, and should not feel pressured into feeling they have to make decisions for others there and then.

We often get lost in the question of who should represent us at meetings (and whether we trust them or not).  But our time would be better spent on why attendance at each meeting is important, and as a result being clear on what the representation is we require.

I wrote recently about the importance of PCNs prioritising delivery over attendance at meetings.  The question that poses is how PCNs can ensure they are effectively represented at meetings if they are not there themselves.

First off I would just reiterate that given the limits of available PCN time, if a PCN is faced with a choice of either ensuring local delivery or attending a system meeting, I would always prioritise the former.  But how then do we ensure that the PCN influence on decision making is not completely abandoned?

This raises the thorny issue of representation.  While the idea is simple enough – one person goes to a meeting to represent a PCN or multiple PCNs – the reality is much more difficult.  How do I and my PCN know that the person who attends on our behalf is going to accurately represent us?  How can we be sure that by not attending the meeting we are not missing out on opportunities and/or resources?

Representation requires trust.  And the trust required for representation is hard to gain.  If I am to trust someone to represent my PCN I am not simply asking for the minutes of the meeting to show that my PCN turned up, or someone to spectate and then feedback afterwards.  I want, in addition to timely and appropriate feedback on the meeting and any relevant decisions made, to:

• Know that my PCN is going to be represented accurately
• Be confident that the representative is not going to put his or her own interests before that of my PCN
• Believe that the reputation of my PCN will be strengthened as a result of my representative’s attendance
• Trust that the representative will make an intervention where one is required, e.g. because the meeting is suggesting something inappropriate/absurd/potentially damaging etc.
• Be sure that the opportunity to build relationships with other attendees will not to be lost

Given the challenge that effective representation presents, how is a PCN to find someone they can trust to represent them?

A commonly suggested solution is to use rotation, either between CDs of different PCNs, or between members of a PCN, where a group of individuals take turns to be the representative.  This stops everyone needing to go, and reduces the risk of any bias to a particular individual or PCN.  However, I don’t like this as a solution.  Meetings themselves are about relationships.  In any regular meeting the attendees get to know each other and find a way of interacting.  If my representative is always someone new they wont understand the dynamics of the meeting and as a result will almost certainly be less able to influence any outcomes.

This then leaves the daunting prospect of me needing to find a single individual to represent me and my PCN at the meeting.  Who can I turn to?  Here we are talking primarily about system meetings, with potentially Board Directors of the CCG, hospital and community trust in attendance.  So in addition to being someone that I trust, I also need someone with an understanding of the system, someone who can hold their own in that company, and someone who can influence the outcomes in at least the same way as I believe I could if attended in person.

The horns of the dilemma facing many PCN CDs then is who can represent me and my PCN at these meetings that I simply don’t have time to attend?  And the default response is generally that there is no one, and that I will just have to find time and go myself.  But then, as I discussed last week, the PCN loses out because delivery suffers as there is insufficient time to both deliver and go to these meetings.

In many ways this brings us back to where we started.  If the choice is delivery versus meetings, choose delivery, and say no to the meetings.  But the real question is not is there someone who can represent me, but how can I create the representation that I need.  That is the question that I will explore in more detail next week.

It will come as no shock when I tell you that the NHS has a meetings culture.  The NHS loves meetings.  There is virtually no situation in the NHS where the default response will not be to organise a meeting.  When emergencies arise, ‘lesser’ meetings are cancelled so that the new, more important meeting can take place.

Integrated care is no different.  It is nearly six years since the Five Year Forward View was published, which was when the idea of integrated care became mainstream.  The idea was to close the divide between health and social care, between physical and mental health, and between primary and secondary care.

There then followed a tsunami of meetings to decide whether an MCP or a PACS (remember them?) would be the best model for integrating care locally.  Integrating care was the clear priority and so that was what filled the meeting schedule.

But 6 years later on it is not clear what impact all of those meetings have actually had.  Now of course the agendas of these meetings have moved on to integrated care systems and integrated care partnerships.  The default NHS response to any new initiative remains having meetings about it, and now PCN CDs are being asked to fill their diaries with these meetings.

The big question then is: should a hard pressed PCN Clinical Director spend any of their valuable time attending these meetings?  If a PCN CD has 2 or 3 sessions a week to carry out the role, how many of them should be spent attending system meetings about integrated care?

The problem with not attending these meetings is the nagging sense that somehow the PCN is missing out.  The concern is that the influence of the PCN will be less if they are not present at these important meetings, or that resources will be diverted elsewhere.

But the reality is that real influence comes from delivering change.  If the PCN is able to build relationships with the local community teams, to find a way of working alongside the local voluntary sector and social care, and to start to make changes happen that make a difference to the local population, not only will the time spent on PCN business become infinitely more worthwhile but also the local system will start to look to your PCN as a place to invest energy and resources.

When the wider system interacts with a PCN, they want to be able to ask the PCN to do something, and once whatever that is has been agreed, they want that to turn into real delivery.  If all PCNs do is turn up to meetings but never delivery anything (because attending the meetings has consumed all of the available time), any influence gained by being at the meeting is quickly lost.  Worse, confidence in PCNs as an enabler of integration is lost and the system starts to look elsewhere for a solution.

A PCN can diligently attend every meeting it is asked to go to and end up with very little influence because it has not had time to make any local changes, whereas a PCN can refuse to attend the majority of meetings it is asked to go to and yet be hugely influential because of what it has achieved.  In the end, delivery will always trump attendance at meetings.

Time is the most precious PCN resource.  PCN CD time and PCN meeting time are extremely limited.  One of the key leadership roles of every PCN CD is to determine how the time available can best be utilised to enable the goals of the PCN to be achieved.  If one of the goals is for the PCN to influence the local agenda, prioritise making change happen locally over attendance at meetings and trust that influence will follow.

Maybe your practice has never worked well with other practices.  Maybe you have avoided it, as far as has been possible.  The new GP contract, with so much money going through the new primary care networks, means this strategy of avoidance is not going to be an option any longer.  What do you do now?

There is a perception that primary care networks are not really anything new, that they have been happening anyway.  I don’t think this is true.  According to the NAPC website, 16% of the population is covered by the forerunner of primary care networks, primary care homes.  NHS England state that according to CCG returns 80% of practices report being in some form of network.  A generous estimate might put the real figure of the percentage of practices that have actively sought to work with their neighbours in some sort of meaningful way in the middle of these two, which would be about 50%.

That means half of practices are in the situation of having to work with other practices for the first time.  It means while half of the practices are building on some sort of foundation, making progress, and generally intimidating those who don’t know what to do, half are simply trying to get their heads around what the new world of networks means.

I have spoken to a number of people recently, asking what advice they would give to GPs and practices in exactly this situation.  I asked an accountant, a lawyer and the Head of Primary Care at NHS England.  Interestingly, all three came up with exactly the same answer.  Go for a drink or for a meal with your local practices.  Get to know them.  Build the relationships.

The questions GPs and practices ask when reviewing new guidance or documents such as the new GP contract are often technical.  What will the accounting relationship be between the new network and my practice?  Will we incur VAT charges?  Who will employ the staff, and where will the risk sit?  These are all valid questions, but, even according to an accountant and a lawyer, they are not the place to start.

A few years ago a colleague of mine took up a new post as an Executive Director in a large teaching hospital.  On her first day she met with the CEO.  He said to her that he didn’t want her to do anything for the first month, just to build relationships.  She was stunned.  She wanted to prove her worth, and was worried that she would be seen as someone without focus on delivery.  But years later she reflected it was the best advice she could have been given.  She said too many people start to try to do things without having relationships in place.  Delivery then happens at the expense of those relationships, not through them.  But because she was given the time to develop strong relationships she was able to deliver far more than if she had just jumped straight in.

The same applies to GPs and practices looking to set up new networks.  The whole rationale of the 30-50,000 population size is about relationships.  It means the people operating within the network can all get to know each other and have a personal relationship, and not be of a size that inevitably creates distant, faceless bureaucracies.  So if the basis of the new primary care network is relationships, the best starting point is to build these relationships.  While it might feel indulgent when the timescales are short, time invested now will repay in buckets in the months and years to come.