10
aug
0

Making the Transition from Commissioner to Provider

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The impact of the formal establishment of Integrated Care Systems and the abolition of CCGs may not have been felt straight away, but there is no escaping the huge consequences this has for general practice.  The question is whether general practice can shift from influencing as a commissioner to influencing as a provider quickly enough to prevent any real damage being done during the transition period.

For the last 30 years, ever since the introduction of the internal market, the influence of general practice has grown through the commissioning route.  It started slowly at first, with the initial forays of GP fundholding, but then steadily grew until Clinical Commissioning Groups were established built around a membership of GP practices.

While the influence of general practice grew through the commissioning route, its influence as a provider steadily receded.  A strong provider voice for general practice has not been needed because GP leaders were already at the system table via the CCG.  Indeed, GP provider representation was actively discouraged because of concerns around conflict to interest.  At best we had GP federations and GP provider organisations purporting to be the voice of general practice provision, but in reality they represented additional provision undertaken by these organisations above and beyond core general practice.

This has been of little concern to the profession because the main representation of general practice takes place nationally via the negotiation of the national contract.  It is this contract that has been pivotal to the sustainability of the service, much more important than any additional local income.

But now this is a problem for two reasons.  First, the representation of general practice at a national level is finding it difficult to secure an effective deal for the profession.  This is encapsulated by the self-defeating policy to promote the withdrawal of practices from the PCN DES, despite all the agreed additional resource for general practice over the last 5 years coming via this route.  This creates a huge risk for general practice, because it relies on a premise that this funding will be reinvested into the core contract instead, when a much more likely outcome is simply that practices will lose control of the PCN resources.

Second, all the signs are that much more practice income will come via the local route rather than via the national contract in future.  This was signalled strongly in the Fuller Report, and backed up by a letter from all 42 ICS Chief Executives.  If this is the case, how organised is local general practice to negotiate as a provider with its local system.  Are LMCs up to the job?  Is the infrastructure of LMCs sufficient for the size of what may be required? While some clearly are, there is a huge variation amongst LMCs across the country.  The system is going to want more ‘integration’ by general practice in return for more resources, so how are PCNs going to play into these discussions?  Will PCNs and LMCs be joined up, or will they be played off against each other?

For the first time in over 30 years local general practice needs to establish its voice and influence as a provider in the local system.  The support that has historically been in place from commissioners will quickly recede in the new system.  Much of the responsibility that has sat with national leaders and the national contract will become the responsibility of local leaders.  It will be up to general practice in each local area to support itself.  LMCs, PCNs, federations and practices will need to work together to ensure local general practice is unified.

27
jul
0

Can GP Federations Continue to Stand Alone?

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The world is moving quickly and the need to take a step back and consider how everything fits together is becoming more and more frequent.  For GP federations the move into Integrated Care Systems (ICSs) is creating one of these moments.

Historically GP federations have been set up in local areas often by a relatively small number of enthusiastic GPs.  They generally began with high expectations, and then over time relationships with member practices have waxed and waned, particularly as it has been challenging for federations to fulfil the delivery requirements needed to establish themselves as a provider and at the same time carry out the amount of communication necessary for practices to feel engaged and part of the organisation.

Then along came PCNs.  Up until that point it had been easy for federations to describe themselves as the ‘at-scale’ arm of general practice, as there were only individual practices and the federation.  But with PCNs came a mandated at-scale operation of general practice in every local area.  Now there are practices, PCNs and a federation, and it has made it more difficult for federations to articulate their role in the system.

The preference has generally been to describe themselves as the at-scale provider across any given area, as their remit tends to mirror old CCG areas and hence be larger than nearly all individual PCNs.  The mainstay of many federations has been the delivery of extended access, and recently federations and PCNs have been undertaking a round of relatively strained conversations to agree what the federation will do and what PCNs will do, now that responsibility for the service has shifted to PCNs.

But it is the emergence of ICSs that is bringing things to a head.  General practice needs to be able to operate as a collective entity within an ICS “place” area.  Within such an area there is often a number of PCNs, an LMC and (if one exists) a federation.  The question is whether, in such an environment, a federation can stand alone as a GP provider organisation, separate from core general practice?

This is problematic because the system wants to do business with general practice as a whole (not a limited company that can access GPs to deliver services).  Whereas in the past federations could point to their practice membership as a proxy for working across all practices, with PCNs in place this is no longer the case as they have a much clearer practice membership.  Federations were never really set up as a way of other organisations being able to do business with general practice, so now federations have a problem.

The most obvious way forward would seem to be to strengthen the federation/PCN relationship.  If federations can be the glue that holds PCNs together they would be perfectly placed to continue to provide at-scale services, provide support for PCNs and practices, and by including the LMC could start to be able to talk with authority in the system as local general practice.

But while some federations have been bolder in taking steps towards taking on the provision of support for PCNs as a new part of its core business, many have shied away from this (often because of emerging PCN/federation tensions, and because of the costs involved).  While PCNs are funded by the PCN DES, federations rely on funding from the delivery of services.  The need to breakeven/fund the federation infrastructure and even generate a return for shareholders has often created a tension in terms of what federations have been willing or able to do in terms of support for PCNs.

The irony is that federations are highly unlikely to be able to generate any kind of sustainable financial return if they maintain their separation from PCNs.  They will increasingly rely on the PCNs for the work (like extended access), and if federations are not the support provider for PCNs then whoever takes this on will end up being better placed to take on any at-scale work.

Without the protection of CCGs the ICSs are not going to tolerate small-scale provider organisations with no real remit.  If federations are not providing the scaled up support the new integrated neighbourhood teams are going to require, and don’t become the organisation that holds general practice together in an area, it is hard to see how they will survive beyond the next few years.

20
jul
0

The Direction of Same day Appointments

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There is no escaping the issue of access to GP appointments.  Now more that ever it is sitting at the top of the national priority list, so what can we expect the future to look like?

There is seemingly a media campaign highlighting the challenge many patients face in obtaining a face to face appointment with their GP (e.g. here).  The highly public nature of this issue means that it is the government’s highest priority for general practice.

At the same time, the erroneous belief that the reason emergency departments are struggling is because patients cannot get to see their GP pervades Integrated Care System (ICS) thinking.  The priority for ICSs is now to ensure that ‘something is done’ about this issue.

This was the context that the Fuller Report was produced in.  Despite the framing of the report as “a vision for integrating primary care”, the framework for shared actions is clear that the number one priority is to, “Develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for patients” p34.

I have written already about the single urgent care teams the Fuller Report proposes.  In this article I noted the lack of clarity in the report about exactly what was intended by the notion, and that much of what was written raised more questions than answers.  However, talking to different people it seems that there is a likely direction of travel.

PCNs are already putting plans together to outline a single model of delivering extended access across each PCN to start in October.  The requirement for on the day demand to be organised across the practices in a way that integrates all of the service offerings and guarantees same day care will be added on to PCNs.  The logical third part of the jigsaw will be to also give responsibility for out of hours care to the PCN.  Thus PCNs will have responsibility for 24 hour delivery of urgent primary care in their area.

PCNs meanwhile will most likely fall much more under the remit of ICSs.  Their rebranding as Integrated Neighbourhood Teams and shift of funding from the national contract to ICSs will mean that performance management will come locally.  Don’t expect this to be as light touch as we have seen in many areas over the delivery of the PCN DES specifications.

This of course has huge implications for practices.  While many areas are working on plans for extended access that minimise disruption for practices (either stick with the existing provider, or enable all or part of extended access to be delivered by practices where there is capacity/will to do so), the same approach is not going to work for in hours appointments where many practices are not able to offer same-day appointments.  GP capacity is insufficient and falling, so a different approach, one that most likely involves the patients of individual practices being seen either in PCN ‘hubs’ or by other practices, will be needed.

For some this will represent an unacceptable move away from the core model of general practice, where individual practices deliver cradle to grave care for their list of patients.  This new model creates limits on where continuity of care is required, and splits urgent access away from the traditional model.  For others it will be a welcome relief from the incessant demands placed on the practice, with no hope of them ever being met.

It seems we have a rocky road ahead.  Many PCNs have found getting to agreement across practices on extended access challenging enough, and the prospect of doing with the same with in-hours on the day demand and potentially even out of hours extremely daunting.  Meanwhile, this will feature highly on the priority list of the new ICSs, and given the wider system pressures it would not be surprising to see many adopt a relatively heavy handed approach.  At the same time there will undoubtedly be a backlash across many parts of general practice because of the challenge it poses to what represents core general practice.

Whatever your views, I think it would be sensible for practices to start thinking about this issue now, and working out how they want the future to unfold.  Getting on the front foot, rather than waiting for the system to impose something on you, seems the best strategy to take right now.

13
jul
0

Can General Practice Operate Collectively?

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Whilst the starting point for general practice to be able to influence the new-in-place Integrated Care Systems (ICSs) is its ability to establish a unified voice, the challenge quickly follows as to whether it can also act and operate collectively.  But is this a bridge too far for independent contractors?

It is one thing for all the general practice organisations in any given area (practices, PCNs, federations, LMCs) to create a unified voice that it can provide into any system discussion.  General practice can create its own leadership team that can work to be the group representing the whole of general practice in an area.  This is an important and crucial first step towards establishing influence in the new system.

Once leadership groups are established they can very quickly become the place where the system and other organisations come to talk to general practice, a helpfully accessible route that has rarely previously existed.  They can also provide a viewpoint on the ideas, plans and strategies of others, and identify what general practice does and does not agree with.

But it is another thing for those general practice organisations on the leadership groups to be able to work together and agree how general practice as a whole will operate.  It is difficult for them to get to a place and agree that this is what PCNs and practices will do, this is what the federation will do and this is how we will oversee and ensure that what we have agreed is working.

Enhanced access is a good example of this.  The debate is often lost in internal general practice arguments as to which PCNs will do what, what the federation will do and how any ‘hybrid’ model will work.  Very few places have been able to establish and present a unified, coherent, local model with a single reporting structure that can feed into the wider system discussions around urgent care.

The Fuller report points to a model of managing urgent care that brings in-hours on the day demand for general practice, enhanced access, and out of hours care all together (Fuller Report p11/12).  This was number one in the list of actions for local systems to take (Fuller Report p34).  Can general practice agree for itself how this model should be introduced, or will it require the system to enforce a model upon it?

The problem is that practices, PCNs and federations are often focussed on their own autonomy and the needs of their own individual organisations, but this is coming at the expense of what is best for general practice as a whole.  For general practice to be able to preserve its overall autonomy, and resist system advances for it to be ‘integrated’ into some existing part of the NHS machinery, it will have to demonstrate to the new ICSs that it is able to organise itself.  The paradox is that individual general practice organisations will have to give up some autonomy in order for general practice as a whole to retain it.

Ultimately it will not be enough for general practice to create a shared leadership group if it cannot then convert that into collective action.  For influence to be real it needs to go beyond having seats at system meetings, because it is not really about how loud the voice is but whether it can actively impact what happens across the system.    Of course, general practice can have more of an impact than any other organisation on the system, but only if it finds a way to operate collectively.

6
jul
0

Is General Practice About to Score an Own Goal?

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I was amazed when I heard that the BMA’s Annual Representative Meeting had voted in favour of GP practice withdrawal from PCNs by next year.  The motion for the, “GPCE and the BMA to organise the withdrawal of GP practices from the PCNs by 2023” was passed with 61% voting in favour, 12% against and 27% abstaining.

The context for this is that we are currently in year 4 of a 5 year contract deal, agreed in 2019.  By the time we reach the point at which this withdrawal is to happen it will be for the last year of the existing deal.  The majority of the benefits of this deal for general practice sit within the PCN DES, and so the call is for general practice to withdraw from the part of the deal with the biggest benefits for its last year.

I cannot be the only one thinking efforts might better be focussed on negotiating the next deal, rather than putting a huge amount of effort into raising concerns during the last year of the existing deal.

We already know that NHS England is not going to negotiate around the existing deal.  Last year was the first year we did not have a negotiated agreement between the GPC and NHS England.  It will not be any different this year, as they will argue exactly as last time that the current deal was already agreed to four years ago.

The wider context is that we have Integrated Care Systems (ICSs) wanting to take control of GP and in particular PCN funding.  The system can see the extra money that is being put in through PCNs, and in particular through the ARRS, and wants to get its hands on it.  Remember £1.8bn of the additional £2.8bn negotiated in 2019 comes through PCNs.

This creates a fairly happy set of scenarios for NHS England.  They can offer to take PCN funding out of the national contract next year so that it can be “topped up” locally by ICSs, thereby increasing the funding going into PCNs and accelerating their development into Integrated Neighbourhood Teams (as per the Fuller Report).  Very little of any extra money would make it to practice level, and the cost would be a big shift away from a national contract and a worrying precedent set ahead of the next 5 year deal.

Alternatively NHS England can give the PCN funding to ICS areas directly (if practices say they do not want it), for them to either route back through general practice or put it through a local lead provider type model.  If general practice does not want the PCN money or staff, then the system I am sure will be happy to take it.  At this point it would be hard to see any other route for general practice to survive other than via integration into other providers.

The LMC motion that was passed in full also calls for, “PCN funding to be moved into the core contract”.  The problem is that this is outside of the control of general practice and is not something that NHS England or the government is going to agree to.  If what the system wants is a general practice that can actively partner with other providers then the last thing it is going to do is act to strengthen its independence.

Withdrawing practices from PCNs at this point in time would be a huge own goal for general practice.  I understand the resentment and dissatisfaction that exists within many practices towards PCNs, but if the aim is to preserve the independence of general practice then this is politically naïve and a move that will do far more damage than good.

29
jun
0

Why general practice needs to act now

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This week will mark the end of the current system of Clinical Commissioning Groups and the commencement of the new system of Integrated Care Systems (ICSs).  It also represents the opening of a window of opportunity for general practice to take action that might not last for very long.

Many consider this current round of system changes to be just another turn in the wheel of NHS structures, the latest in a line of changes that have been happening every few years for at least the last 20 years.  But my sense is that this is a much more fundamental change, and one that could mark the beginning of an (even more) difficult period for general practice.

The end of CCGs marks the end of the purchaser provider split and the internal market that has been the organising principle of the NHS since 1990.  Alongside that principle has always been the idea of a primary care led NHS, and this also is coming to an end.  Instead, ICSs are based on the principle of providers working together, but of course not all providers are equal and the dominance of trusts and in particular acute trusts creates huge risks for general practice around priorities, contracts and funding.

How can general practice future-proof itself within the new system?  What action can it take?

The good news is that it seems that there is unlikely to be a nationally prescribed ‘solution’ for general practice.

When the system talks about needing a solution for general practice it means how can it work with general practice playing its role as a partner provider in developing system-wide responses to the challenges local health systems face.  With the GP leadership role of CCGs gone, there is no obvious route for working with general practice.  When there are upwards of 50 practices, 10 PCNs, and maybe 2 or 3 federations and LMCs in any area it can be virtually impossible to find any kind of consensus across general practice, let alone a shared commitment to collective action.

Despite Sajid Javid floating the idea of GP nationalisation earlier in the year, and the incorporation of general practice into an existing NHS organisation as the best solution, the Fuller Report very much points towards the development of local solutions for general practice within each system context.

The challenge for general practice, then, is to demonstrate that is can organise itself in any given area, that it can be united, and that it can create a consistent and influential voice.  If it can do this effectively, it can future proof its own autonomy as there is no need for the system to go down the route of asking another organisation to take over control.

But there is no time to waste.  It wont be long before ICSs find their feet and start to try to impose solutions upon general practice.  While currently this might seem well outside their control, if funding for general practice shifts from national to ICS level then they will most likely have the levers to be able to make this kind of change happen.

There are plenty of areas up and down the country already working hard to try and create a local cohesion across GP practices and organisations.  It is really important that everywhere starts to consider how to develop this in their area.  If practices do not start this work now, it may end up being too late and someone else may be brought in to do it to them.

22
jun
0

The Future of General Practice funding

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Hot on the heels of the Fuller Report, there is now talk of a reform of general practice funding allocations, all of which is pointing to some big changes coming for how the money flows to general practice.  What exactly do we know, and what is likely to happen?

Let’s start with the Fuller Report.  This says a number of interesting things when it comes to funding.  It reiterates the point made by NHS England recently when it says, “We welcome the clarity from NHS England that staff in post will continue to be treated as part of the core PCN cost base beyond 2023/24 when any future updates to the GMS contract are considered” (p19).

This is welcome, as many had been concerned that general practice would be expected to pick up the staffing bill for the ARRS staff post 2024.  It is noteworthy, perhaps, that the description is of these staff being part of the  “PCN cost base”, given the push for PCN funding to come via ICS’s in future that I will come on to.

The report also indicates that no change is planned to general practice funding until after the current five year contract has run its course – the recommendations on p35 around funding are that they should take place “beyond 2023/24”.  Nikki Kanani’s recent comments were also all about planning for the next contract after the current 5 year one.

However, the big push in the Fuller Report is for primary care funding, including general practice funding, to shift from being nationally to locally driven.  The report states, “National contractual arrangements, including for PCNs, have provided essential foundations including for chronic disease management and prevention. But they can only take you so far. As already highlighted in the report, getting to integrated primary care is all about local relationships, leadership, support and system-led investment in transformation. ICSs putting in place the right support locally will be enabled by maximising what control ICSs have over the direction of discretionary investment. This should be looked at by NHS England as part of the implementation of recommendations.” (p28).

Now in case that was missed by anyone the report was accompanied by a letter from the 42 Chief Executives of the new ICSs which reinforced this very point, repeating it almost verbatim, “National contractual arrangements, including for PCNs, have and will continue to provide essential foundations. But they can only take you so far. Getting to integrated primary care is all about local relationships, leadership, support, and system-led investment in transformation.”

There will undoubtedly be a variation across the ICS CEOs in how they view primary care and the role it can play.  But what they can agree on (unsurprisingly) is that they would like the funding for general practice to come via them rather than via a national contract.  It is hard not to believe that this shift of funds was at least to some extent behind the universal support ICS CEOs displayed for the report.

The extent of this shift is made clear in the annex at the very end of the report.  They want firstly the Additional Role Reimbursement Scheme to be delivered via ICSs not via a national contract (“Specifically consider, with DHSC and HEE, how the (ARRS) scheme should operate after March 2024, including the role of ICSs in working with national colleagues and PCNs in delivering it” p35), and secondly any additional funding for general practice to come under the control of local systems (“Move to greater financial flexibility for systems on primary care… Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35).

The report also sets the context for Nikki Kanani’s comments at the recent NHS Confederation Expo about reviewing the national funding allocation formula as part of the contract negotiations for the next contract from April 2024.  The report says, “It is also generally accepted that the distribution of primary care funding to neighbourhoods is not always well aligned to system allocations and underlying population health needs – and we need a concerted local effort to try and fix this.” (p28).

All of this, then, is pointing to a shift of resources out of the national contract after this 5 year deal expires, with far more to be allocated via ICSs.  The distribution of this additional resource (it seems) will be made by ICSs dependent on population health needs, regardless of the specific local needs of primary care providers.

All of this means there are a number of risks ahead for general practice.  First, ICSs are governed by a requirement to break even across the system, and cannot ringfence funds in the way areas could in the previous system when commissioners held individual contracts with providers, so funding via an ICS cannot be guaranteed in the same way as funding via a national contract.

Second, the allocation of locally distributed funds is likely to be based on population health need, meaning the distribution across practices will vary significantly.  Third, the ability of general practice to influence the direction of funds within a local ICS is far less than its collective ability negotiating a national contract together.  Fourth, there does seem to be some form of play for some of the existing PCN resources to shift out of the national contract and into local control.  And finally once resources are within ICS control they don’t have to come direct to general practice but could come via a partnership mechanism, i.e. via a third party provider of “support” such as an acute or community trust, which would likely further impact on the independence and autonomy of general practice.

My view for what it is worth is that general practice should think extremely carefully about agreeing to any significant shifts of funding from the national contract into local systems, but the GPC appears to be positioning itself badly in this regard with its position on the PCN DES, and so whether the service ends up with any choice in the matter remains to be seen.

15
jun
0

The Fuller Report: Single Urgent Care Teams

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There is much that is worthy of further discussion in the Fuller report.  Last week I considered integrated neighbourhood teams, and this week I take a deeper look into the idea the report introduces of single urgent care teams.

There is a context for this notion, which is the Our Plan for Improving Access for Patients and Supporting General Practice paper published last October.  That particular paper incurred the wrath of general practice, and the Fuller Report does seem to be trying to tread a difficult line between a national desire for the GP access ‘issue’ to be resolved, whilst avoiding letting it dominate the whole report.

Hence, while the paper introduces the idea of single urgent care teams in the middle of the document, it is telling that the number one action emerging from the report is to, “develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for practices.  This should be for all patients clinically assessed as requiring urgent care, where continuity from the same team is not a priority” p34.

It is also hard not to believe that implicit behind this idea is the erroneous belief seemingly shared by much of the system that lack of access to urgent care in the community (i.e. GP access) is the primary cause of the problems experienced in A&E and the wider urgent care system.  The report actually says that this change, “can also help to reduce demand on other urgent care services across the NHS iv”, although the reference it uses is of a video of how a practice has this system in place without any reference to the knock on consequences for the rest of the system.

This will inevitably lead to this particular action taking a high priority in the majority of Integrated Care Systems.  But what is the action?  The report states that it is for, “primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them” (p11).  “Same-day access for urgent care would involve care from the most clinically appropriate local service and professional and the most appropriate modality, whether a remote consultation or face to face” (p34).

It involves taking, “general practice in-hours and extended hours, urgent treatment centres, out-of-hours, urgent community response services, home visiting, community pharmacy, 111 call handling, 111 clinical assessment – and organise them as a single integrated urgent care pathway in the community” (p11/12).

But despite my best efforts, I am still not 100% sure what this means.  Maybe the idea of the paper is to build scope for local interpretation rather than dictate a one size fits all model, and this is why it feels difficult to nail down the exact intent of what is written.  Is it saying that all the on the day demand needs to be managed by a single team, and so that will include the team currently managing this within each practice?  Or is it saying that each practice will be a virtual part of a wider community team, operating with a single triage and capacity management system?  Or is it saying something else?

Either way, the implication is that each practice will no longer be managing its on the day demand separately from other practices.  If the model is going to “guarantee same day access”, what if a practice cannot offer same day GP slots to its patients?  Are those patients going to be seen by a GP at another practice?  The implications of a single team across a neighbourhood for managing all of this demand are enormous, and the only examples given in the report operate at a single practice level.

The model is also seemingly based on patients who ask for a face to face GP appointment being redirected to either a virtual appointment or an appointment with an alternative practitioner (and now add in alternative provider), something that practices have been articulating with little support for a number of years.  Meanwhile both NHS England and the government have been insisting in the national media that anyone who wants a face to face GP appointment can have one (regardless of need).  However, no action on a national communications about-face appears within the paper.

The vagueness around this idea is both an opportunity and a risk for general practice.  It is an opportunity because if this is really to be a system where solutions are generated locally as opposed to imposed nationally general practice can create its own interpretation of what it means, turn it into something useful, and then use the authority of the report to access system funding to support its implementation.  It is a risk because others may start to impose their interpretation of what it means on practices in an area, citing the report as their authority for action.

It highlights once again the need for general practice to organise itself locally so that it can positively influence how things develop.  A united local general practice can work together to make the most of the opportunity, but where no such unity exists the risk will almost certainly prevail.

8
jun
0

The Fuller Report: Integrated Neighbourhood Teams

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There are some individual elements within the Fuller Report that are worth exploring in detail to try and understand what they mean, and what the implications are.  The first of these is integrated neighbourhood teams.

Integrated neighbourhood teams are described as being “at the heart of the new vision for integrating primary care” (p6).  The clear action at the end of the report is to “enable all PCNs to evolve into integrated neighbourhood teams” (p34).  In terms of timescale, “systems should aim to have them up and running in neighbourhoods in the … most deprived areas by April 2023… and move to universal coverage throughout 2023 and by April 2024 at the latest” (p7).

So integrated neighbourhood teams are to be an ‘evolution’ (replacement?) of PCNs, and a rapid one at that as this is expected to happen this year, or within a maximum of two years.

What exactly is an integrated neighbourhood team?  The problem with the report is that it tries not to be too prescriptive to allow local areas to create their own versions that will work locally, but of course this means there is a lack of definition when it comes to the detail of what is intended.  It does say they will be where, “teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities” (p6).  The clear intention is to bring all providers in a PCN footprint together.

The obvious question, then, is how will this happen.  We know when PCNs were first introduced the clear expectation was set out that these teams should all become part of the PCN Board, but in most places that just has not happened.  This is because it is hard finding ways of enabling the practices in a PCN area to work together effectively, and PCN leaders have done a great job of making this happen.  But this relies on those practices believing they are retaining an element of control, albeit collective control, or else many would just not be prepared to give up the individual practice autonomy the joint working requires.

This report by ICS leaders displays an element of frustration with the pace of progress of PCNs (or else why produce the report?) and wants to fast forward within one or two years to a model of all organisations working seamlessly together around PCN populations.

According to the report, the reason for this perceived lack of progress is, “a lack of infrastructure and support (which) has held them back from achieving more ambitious change” (p6).  The challenge of enabling joint working across practices within a PCN is ignored.  And so the prescribed remedy is “a systematic cross-sector realignment to form multi-organisational and sector teams working in neighbourhoods. For example:

  • full alignment of clinical and operational workforce from community health providers to neighbourhood ‘footprints’, working alongside dedicated, named specialist teams from acute and mental health trusts, particularly their community mental health teams
  • making available ‘back-office’ and transformation functions for PCNs, including HR, quality improvement, organisational development, data and analytics and finance – for example, by leveraging this support from larger providers” (p6-7)

Does this mean, effectively, a takeover of PCNs by the system, i.e. that the practices in the PCN become one partner of this new system, that has its own infrastructure, leadership and (potentially) place within an existing organisation?  Maybe.  Local interpretation means that if a local ICS wants to interpret it like this it probably can.

The key is where the leadership of these grander integrated neighbourhood teams will come from.  Who will be in charge and have accountability for them?  It does seem unlikely that system organisations will all put resources into these teams and at the same time totally cede control of them to the PCN practices.  This is what the report says about this:

“The role of PCN clinical directors in the future will be essential to the leadership of integrated neighbourhood teams… More focus needs to be given to the development and support of clinical directors beyond the current basic arrangements provided through the national contract, including the local provision of sufficient protected time to be able to meet the leadership challenge in integrated neighbourhood teams.  Some systems will want to go beyond this and use even more innovative ways to support clinical directors to expand and develop their integrated neighbourhood teams, for example:

  • some neighbourhood teams may offer an opportunity to develop different areas of focus and specialisation, with senior GPs serving as the ‘consultant in general practice’ – working across prevention, chronic and urgent care as part of wider teams
  • securing the specialist input from secondary care required in neighbourhood teams, as part of job planning for consultants
  • supporting community partners to operationally embed relevant teams as an integral part of existing PCN teams, recognising that the integration of community and mental health services with primary care is crucial to delivering more integrated care for patients in the community, as set out in the NHS Long Term Plan” (p22)

What should we make of this?  It seems to be saying PCN Clinical Directors will be the first port of call when it comes to who will be leading these new integrated neighbourhood teams.  But how many PCN CDs are going to be able to commit the three (or more) days a week this expanded role is going to require?  Does this then mean the bullets above are alternative leadership options?  It is not a huge step to see these being led by individuals from community trusts, mental health providers, or even secondary care.

As a minimum the implication is that the management infrastructure (if not the clinical leadership) will come from an existing provider (cf the action on p34 “baseline the existing organisational capacity and capability for primary care, across system, place and neighbourhood levels, to ensure systems can undertake their core operational and transformational functions” – I don’t suppose for one minute the answer will be to put more funding into a standalone PCN infrastructure).

The report pushes hard for additional resources for these teams to be allocated at an ICS level (as opposed to the current model of nationally via the PCN DES).  If this is the route of future additional funding for general practice (if this year’s contract negotiations told us anything it is that any new money for general practice has to come via PCNs or their successors), and the leadership and management of these teams increasingly sits outside of general practice, the profession could quickly lose control of its own resources.

Integrated neighbourhood teams are coming, and they are coming quickly.  Behind the attractive picture of clinical teams all working in harmony across the PCN, there are big issues of leadership, ownership and control that need to be played out in each area.  General practice will need to pay close attention to how this happens because of the significant consequences it will have for its own future.

1
jun
0

Trying to Understand the Fuller Report

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There are some far reaching implications of the Fuller Report for general practice.  However, getting underneath exactly what they are and understanding what the report means for practices is far from straightforward.  For me this is primarily because of the way this report has been written, published and launched.  I have picked out four points to note about this here.

The first is that it is not a report about the future of general practice.  Indeed, the report goes to great lengths to insist that it is about all the different parts of primary care, and even then that is about how primary care should be ‘integrated’ not about its future per se.

There is, however, no escaping the fact the two are inextricably linked, despite this seemingly being something the paper tries as far as it can to ignore.  To give two examples: the paper pushes hard for resources for general practice to shift away from the national contract to come under the discretion of local systems (“Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35); the paper also mandates that there should be a single system of managing urgent care in every neighbourhood (i.e. across practices).

These are huge changes for general practice, so it does seem specious to argue that this is only about primary care integration and not about the future of general practice itself.

Which brings me to the second point about the paper.  It is not an options paper, or a discussion paper, but is rather produced as a fait accompli – that this is the only possible way forward.  The paper outlines what it describes as a ‘vision’ of the future, and finishes with the actions needed to begin its implementation. For such a radical change you may have expected a period of discussion, deliberation and consultation, but because this is about ‘integration’ not general practice there is apparently no need.

The third point to note is that the paper is not an easy read.  There is no easy to navigate contents page, no numbering or anything to help an unseasoned observer make sense of what they are reading.  There is a great deal made of the three elements of the new vision, but very little on the what all that means for the existing models and ways of working.  In some ways I was left at the end of the paper feeling that much more was implicit than explicit.

The fourth point is about the launch of the paper itself.  The report is accompanied with a letter of support from all 42 of the ICS Chief Executives.  It is explicitly noted in the document that the Chairs of 9 workstreams and 4 task and finish groups all “endorse its findings” (p37).  Following the publication of the report there were then lots of seemingly pre-orchestrated messages of support for the report and a reinforcement of the idea that this is the only possible way forward.  Have a look at this message from the Chair of the RCGP, and even this one from the BMA.

Now it may be that all of these organisations were fully engaged in the production of the report, and what has emerged is a consensus model that all parties concur is the best way forward.  I just find the lack of any clearly articulated implications of the report surprising (in particular from the BMA and RCGP), even if they support the report.

All of this leaves me with the sense of a very highly politically managed process with the report trying to be pushed through, without the debate and discussion that you would normally expect for such a significant change.

It is for individuals to make their own mind up about the attractiveness of the vision laid out in the report and the extent to which they sign up to the proposed way forward.  My ask would be that more clarity is brought to the implications of this report for general practice before these decisions are made, but my fear is that rapid national agreement will quickly push any real debate to a local level and the course will already be irreversible.

25
may
0

Why Your PCN Finances are not Transparent

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A common complaint many GPs have about their PCN is that the finances are not transparent.  Behind the comment lurks an unspoken implication that not every practice is receiving their fair share, or that certain practices are being favoured.  However, the reality is PCN finances have been set up in such a way that it is hard for anyone in the PCN to really understand the financial position of the PCN.

Why is this? There are number of reasons.  The first is that the funds received by PCNs come in various different formats.  Some money (the £1.76) goes directly to practices.  While most come into the PCN bank account, the timing and amount varies (and is impossible to predict!).  The biggest pot of money, the ARRS, has to be reclaimed based on actual expenditure.  Other pots are paid according to a formula (e.g. PCN CD funding, the £1.50).  Clarity as to when any of this funding will arrive has never been that forthcoming.

Some of the funds are paid on performance, the main one being the Investment and Impact Fund (IIF).  The payment for this ends up being made in the year after the achievement has been calculated, i.e. it will only be sometime probably towards the end of this quarter when PCNs will receive the payment for achievement of last year’s IIF, and they are only just finding out what that amount will be (and there are often reasonably sized discrepancies between what PCNs expect and what the system claims they have earned).

Every year changes are made to the allowances that PCNs can receive, and during Covid these changed in year as well.  The restrictions on how different pots of funding that the PCN receives also vary.  Some have a very specific way in which the funding can be used (e.g. ARRS), whereas others have far less restrictions (e.g. the £1.50).

Then each local area has different funding streams available to PCNs on top of those in the national DES.  These vary considerably across the country, but we are increasingly seeing many local enhanced services with PCN components (if not being entirely commissioned via the PCN).

The financial questions for a PCN to work out then include cash-flow (do they have enough money in the bank to pay the bills), overall income and expenditure (by year), and what all of this means for available expenditure at any given point in time (e.g. can we afford an IIF clinical lead).

Larger PCNs are now multi-million pound businesses, with a relatively complex financial framework sitting behind them.  The funding provided for PCNs to manage these finances are lumped in with all the other running and leadership costs.  If a PCN has a bookkeeping function, even allowing members to access that system does not provide transparency because it will just provide a snapshot of the cash position and give no real sense of the overall financial position of the PCN.

What PCNs need is financial management accounts, i.e. someone with the skills, expertise and financial nous to convert all the financial flows and commitments and create easy to understand summaries of where things are, what is expected and what financial options the PCN has at any point in time.  But how can a PCN afford what it needs given the running cost resources it has?  Some PCNs use a shared resource, e.g. from the local federation, that can make this a possibility.  But for many the costs of obtaining this level of financial support simply feel too prohibitive.

Finally many PCNs have not yet established their own financial strategy.  Is the plan for the PCN to reinvest as much available resource as it can into practices (like a PCN dividend), or is the plan for the PCN to reinvest any available resources into something like support and infrastructure that builds capacity for medium to long term collective sustainability and resilience?  Sometimes concerns about transparency come because different members have different financial expectations of the PCN, without the explicit conversation ever having been held.

My sense is we have reached the point now, where the sums involved have become so significant and are going to increase again over the next two years, that PCNs can no longer manage without effective management accounts, and that making the most of the opportunity of PCNs requires a worked through, agreed PCN financial strategy.  If nothing else, it will at least enable PCNs to get past the complaints about lack of transparency!

18
may
0

4 Key Risks ICSs Pose for General Practice

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It is less than 6 weeks until Integrated Care Systems (ICSs) go live, and yet most of us are still trying to get our heads around exactly how they are going to work.  While some are sticking with the “nothing much is gong to change” mindset, the reality is that this transition does pose significant risks for general practice.  I am not trying to be a prophet of doom, but understanding the risks is the first step to being able to mitigate them.

Here are 4 key risks the shift to the new system creates for general practice.

  1. Less funding for general practice

The biggest risk is that the funding coming into general practice reduces.  There is already pressure on the new ICSs to break even.   It is no longer individual organisations that are overspending, but rather whole systems. What this means is that if the hospital is overspending, general practice funding is on the table as a means by which the system can get back into balance.

This could manifest in a whole number of ways.  If general practice funding levels are different across different parts of the ICS, the system could argue that the funding should be reduced across all areas to the level of the lowest.  If different levels of funding are used for out of hours services, arguments are likely to be made that it be reduced to the level of the lowest.  When a system is deciding upon how much discretionary expenditure to make on general practice (remember all local enhanced service funding will come under the jurisdiction of the ICS), these decisions will be made within the context of the overall financial situation of the ICS.

  1. System decision making more likely to negatively impact GP practices

With such important financial decisions being taken at an ICS level, it will be important for general practice to have a strong voice at these discussions.  The problem is there is no obvious route for this to happen.  The mandated GP on the ICS Board only has a few sessions a week, and the size of the ICSs mean there is a huge risk of a disconnect between ICS decision making and individual GP practices.

If the large providers dominate the decision making, then it is much more likely the decisions will be made in their favour.  Some hospitals have already started to make an argument that because of all the fixed building costs within their estate it would be better for more work to come to them from general practice – with the associated funding!  It is thinking like this that poses one of the biggest threats to general practice.

  1. Loss of support for GP practices

Many will remember when CCGs were first created and the commissioning of general practice moved to NHS England.  Systems lost all of the relationship managers that had existed in PCTs, and the whole thing was such a disaster that worries about conflicts of interest were put to one side and responsibility was returned to CCGs to restore individual contract relationships with practices.  But with the move to ICSs it could well be that we see the same mistake made again, only this time with no CCGs available to give it back to.

If ICSs mean the system decides to take a hard contracting line with GP practices, with no thought or concern for the individual pressures and challenges practices face, then it could quickly become a very hostile environment for practices.

  1. Less protection for the independent contractor model of general practice

This shift to ICSs is taking place at the same time as the Secretary of State is declaring his preference for a nationalised model of general practice.  ICSs are all about providing support services at scale across the NHS, and doing things once that only need to be done once.  It doesn’t take a huge leap of imagination to see ICSs thinking that a more efficient (ie less costly) model of general practice would be if multiple practices were consolidated into existing organisations (making use of their existing back office infrastructure etc etc).

In the past we have had sufficient GP leadership in CCGs and across the system to counter such thinking.  But it is questionable as to whether this voice of reason is going to be loud enough in the new system, and the protection that has previously existed is likely to be sorely missed.

11
may
0

Why the End of CCGs is Bad for General Practice

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GPs have not been overly enamoured with CCGs.  It was not long after their inception in 2013 that the promises of GP control of the funding fell flat, and that they were subsumed within the tentacles of the all-encompassing NHS system.  Now they are so far removed from any individual practice that the membership model sold to general practice 10 years ago is barely recognisable.  But in only a few years’ time GP practices may well be reminiscing fondly about the days of CCGs.

This is primarily because the system replacing CCGs contains no obvious place for general practice.  Integrated Care Systems (ICSs) are more than just the latest incarnation of the NHS.  They represent the first shift away from the purchaser provider split that has been at the heart of the NHS since 1990.  Whatever our views on the internal market, it was always accompanied by an underpinning philosophy of creating a primary care led NHS.

ICSs mark the end of any notion of a primary care led NHS.

The internal market was first introduced in 1990 via the National Health Service and Community Care Act.  The very same act introduced GP Fundholding.  Since then we have had over 30 years of different versions of trying to create a purchaser provider split where primary care held the purse strings: Primary Care Groups; Primary Care Trusts; Practice Based Commissioning; and, in what was the last throw of the dice, CCGs.

It is not just CCGs that are going, it is the whole notion of an internal market, and the concept of a primary care led NHS.  Instead, the new system is supposed to be based on partnerships, on providers working together to agree how to distribute resources to deliver the best outcomes for patients.

In this system there is little to no incentive for anyone to find a seat for general practice at the leadership table.  The less people around the table, the easier it is to reach agreement.  Hospitals are merging and creating “hospital chains” so that they will essentially be one hospital per ICS.  There is also roughly one community trust and one mental health trust per ICS.  And even then sometimes these organisations are merged.  In all likelihood the bigger you are, the more say you will have in these “partnership” discussions.

By contrast, at 42 ICSs we are looking at c170 practices per ICS, plus c30 PCNs, and maybe a couple of LMCs and federations, so somewhere in the region of 200 general practice organisations per ICS, all with little or no track record of being able to operate collectively.  In a system where bigger is better and less is more, general practice is not in good shape.

The consequences of this will be real for general practice.  Systems are under real pressure to break even, and the “do whatever is necessary, whatever it costs” pandemic mentality has already disappeared.  In this environment, if an ICS has three different levels of funding for general practice across three areas expect it to level down not level up.  Once CCGs are gone, who will be left to argue the general practice corner?  Are we going to pin all our hopes on the GP representative on the ICS Board?

Ultimately the loss of CCGs is going to leave general practice exposed, with little or no voice in important system discussions.  Local general practice needs to be working hard right now to mitigate this risk.  The government’s answer seems to be to nationalise general practice and put it under the control of one of the local trusts.  We are waiting to see what the Fuller Review recommends.  It would be better if local general practice could take advantage of the window of opportunity that is left to organise itself as a force to be reckoned with, because at least then it will be controlling its own destiny.  In this article for PCN Pulse I outline the steps general practice can be taking now to make this happen.

4
may
2

3 Things Practice Can Do to Make the Most of the Additional Role Reimbursement Scheme (ARRS)

Posted by Blogs, The General Practice Blog2 Comments

The most significant additional investment into general practice at present comes via the PCN DES, and the much of that arrives in the form of the ARRS.  We are three years into the five year deal, which means there are only two years left of significant growth of this funding.  Further similar increases in future seem unlikely.  How can practices make the most of this additional resource?

The scale of the opportunity remains relatively high.  Most PCNs have not yet spent their full allowance to date, and some of last year’s expenditure was often used for the vaccination programme rather than being deployed recurrently.  This means that many PCNs have getting on for £1M available to invest in new roles over the next two years.

There are three things that practices can do to make more of the opportunity of the ARRS.  The first is to think differently about the roles that are needed.  To date the process of identifying which roles to employ has often consisted of looking at the list of available roles and choosing the ones that the practices most liked the sound of.  But continuing to do this is likely to mean practices will fail to make the most of the opportunity this funding presents.

We know that general practice workload will continue to increase. Demand from the local population will continue to go up, and the advent of ICSs is likely to accelerate the shift of activity from secondary to primary care.  At the same time, the number of GPs continues to fall, as despite the push for extra GPs the number leaving continues to exceed those entering the profession.

This means that for general practice to be resilient into the future the model has to change from one where all the activity coming into practices defaults to a GP, to one where the service is led by GPs but delivered by a much wider range of professionals.  This is the only way it will be sustainable.

What the ARRS provides is an opportunity to bring in the new roles that are needed and change the way general practice operates.  If practices spend some time working out what workforce they want in two years’ time, they can then use the opportunity of the ARRS to create a more fit for purpose workforce and employ the roles that will enable this vision to be realised.

The second is changing the approach to the PCN DES work.  At present the approach is generally that practice staff focus on practice work and PCN staff focus on PCN work, and only support practice work if they have any capacity left over.  As a result the additional roles feel like an additional burden on practices because of all the training and supervision that is required, and their time is sucked up meeting the increasingly onerous requirements of the PCN DES.

A better way to think about this is in terms of the totality of the workload (across practices and the PCN) and the totality of the workforce, i.e. how do we incorporate the ARRS staff to create a total workforce able to best support both the practice and PCN requirements.  By keeping such a strong division between practice and PCN work we are preventing ourselves from making the most of the workforce we do have.

The third is not to underestimate the need to invest in a change or redesign process to go alongside the introduction of the new roles.  Incorporating the new roles effectively means changing the way we operate.  If we don’t we are simply trying to plug holes in a sinking ship, rather than building ourselves a new boat.  But this of course requires additional investment and time, both of which are in short supply.

One way round this however is a creative use of the care coordinator role.  So if, for example, we are changing the way practices in a PCN manage prescriptions using pharmacists and pharmacy technicians, then we can use a care coordinator as a change resource to support the change of the prescription process.   Once they have done this they can then be a resource to support the change to the way MSK presentations are managed across practices using an ESP (etc etc).

The ARRS is an opportunity for practices to start to build a model that will be resilient into the future.  But it won’t happen automatically, and practices need to act now to make the most of it because in two years’ time it may well be too late.

27
apr
0

Are PCNs the Battleground for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

The NHS is undergoing some significant changes right now, and the implications for general practice are potentially hugely significant.  Could it be that whoever ends up providing the support that PCNs need in fact ends up being the organisation that controls general practice?

PCNs are the place to where all the additional resource into general practice is being channelled.  This is the crux of five year deal agreed in 2019, and when the GPC tried to renegotiate this this year, and put more into the core contract, they were met with short shrift.  Instead the message was very much that PCNs are here to stay.

The priority for the NHS with the shift to Integrated Care Systems (ICSs) is for general practice to be able to act as a “partner” in the system.  What this means is that in any individual “place” area they want one way of contacting and doing business with general practice (instead of c50  if there are for example 40 practices, 7 PCNs, 2 federations and an LMC).

It is not a huge leap to think that not only will any additional resource for general practice continue to be channelled through PCNs, but also that ICSs will shift all additional, non-core GP funding through PCNs.  Indeed it would not be a huge surprise if all the PCN funding shifted at the end of the 5 year contract from national terms to local ICS-based terms, to allow “effective local tailoring of the resource to local needs”.

PCNs, therefore, will continue to grow, and potentially take on a increasing role in relation to access and quality across all of its member practices.  PCNs already need far more of an infrastructure than they have (think training, HR, finance, governance, performance etc), and this need only becomes more pressing with further growth and investment.  There also needs to be a bringing together of the PCNs within any place area, to make it workable for the system as a whole.

Where does this infrastructure come from?  One of the other provider organisations in the ICS is the most obvious solution.  Such an integration sorts out the infrastructure issue, as general practice and PCNs can simply tap into the already existing quality, estates, HR (etc) functions within that organisation.

While this might feel like too big of a leap, our Secretary of State seems to have already nailed his colours firmly to the mast with his support for the recent think tank paper extolling the virtues of the vertical integration of general practice and its assimilation into acute trusts.  ICSs want to be able to do business with general practice, and this will be far easier if it is all sitting within an existing organisation with a Board and Chief Executive and clear lines of accountability.  For the other provider organisations within an ICS, one of them taking this on seems a far more attractive option than anything else, if for no other reason than it limits the number of providers around the ICS table.

The alternative is that general practice takes this on and organises itself.  The GP organisations in an area can choose to come together and create a single leadership team, and bring the LMC, federation and PCN leaders all into one group.  This group can start to operate as the leadership team for local general practice.  They can build on any existing infrastructure they have, such as that within their local federation, and work with the CCG primary care team to take on more of the resources that are currently sitting there.

I am not underestimating how difficult a task this is, but there are places up and down the country who are starting to work this through and put it into place.

Nobody else will want this.  It is easier for them to work with the existing provider organisations.  For them, waiting for the inevitable requirement for someone else to need to take this on is the easiest option.  While it might feel like a big change for general practice to make, it might also be the only opportunity general practice has to secure its independence into the future.

6
apr
0

How is our PCN doing?

Posted by Blogs, The General Practice BlogNo Comments

As we come to the end of the third year of the PCN it is a natural time to review how things have gone so far, and to consider what might need to be different going forward.  But how do we know how our PCN is doing?

I am struck by the number of PCNs that tell me that they are “behind other PCNs”, even when to me they seem to be extremely well.  Sometimes we hear success stories from other PCNs and assume that this is what “everyone” is doing, and that we are somehow falling behind.  But PCNs are not a race or a competition, and it is up to each PCN to determine what success looks like for itself.

I wrote last time about the importance of a PCN vision, and the need for the practices in a PCN to set their own direction to determine what they want from the PCN.  One measure for how well we are doing is the progress we are making against our own priorities for the PCN (which may well be different from those of other PCNs).

But it is not the only measure.  At their core, PCNs are a joint working initiative across the member practices.  Whatever desired outcomes the PCN has set, a key metric for any PCN is the level of trust that exists between the members.  The more we trust each other, the easier working together becomes.  And this is where we get into the importance of the culture of the PCN.

When you ask member practices about the PCN and how well it is doing the response is rarely about whether the PCN is achieving its goals.  Instead the framing of the response is often about how involved they feel in the work of the PCN, its relevance to them, and its impact (positive or negative) upon them.

So while in part the response is about the level of alignment between the PCN’s goals and the practice or individual’s goals (e.g. is it reducing or increasing my workload), it is also about the way the PCN operates.  Do member practices feel involved in decision making?  Do they feel able to shape the activities of the PCN?  Do they know what is going on?

This is essentially what the culture of the PCN is – “the way we do things around here”.  If the culture is strong, is built on a solid and developing foundation of trust, and the member practices are happy with it, then the PCN has a solid foundation to go on and achieve whatever it wants to in the years ahead.  But if there is unhappiness with the culture, complaints about the lack of communication, disengagement from practices, and a general lack of trust, then regardless of what has been achieved so far it is likely to be a difficult road ahead.

Determining how well we are doing in a long term joint working enterprise like a PCN needs to be as much in terms of how we do things as what we have achieved.  If we are taking time out to take stock of where we are as a PCN (and I strongly recommend that you do!), then make sure to spend as much time on how the PCN is working as what you want it to achieve.

30
mar
0

Time to Revisit the PCN Vision?

Posted by Blogs, The General Practice BlogNo Comments

It is always an interesting to hear the response when I ask the leaders of any PCN whether they have a PCN vision.  Most commonly they recall doing some work on this a few years ago when the PCN first set up, but equally could not tell you what it is.  So is it time to revisit the PCN vision?

The problem is most of the work that goes into establishing what the PCN vision should be focusses on the words in the vision itself.  PCNs end up with some form of ‘vision statement’ that acts as the end product to the work, which is often some noble statement about supporting people to have better outcomes and working in partnership (etc).  But what happens to it, other than it ending up on the PCN website or being used as evidence in the latest PCN maturity matrix assessment?

It is not a surprise, then, that members of the PCN cannot remember what the PCN vision is, because its relevance to the members is limited at best.

The point of a vision statement is to establish why you are undertaking the enterprise in the first place.  Why has each practice signed up to the PCN DES?  What do we want out of it?  What problems are we all experiencing that we think the PCN may be able to help with?  If the vision statement can get to the heart of this, it becomes much more powerful.

The simpler the PCN vision is the better.  Compare these two PCN vision statements (these are real, anonymised PCN vision statements):

  • Member practices of XXX PCN will work together to improve access to the local community. Extending the range of services available to them, by helping integrate primary care with wider health and community services. We will work in collaboration with others – health and social care services, the voluntary sector, community groups and local people – to make best use of available resources, creating a seamless approach, whilst making sure that everyone gets the right support, in the right place, at the right time.
  • To create a sustainable future for our practices.

Which is most powerful?  The point of a vision is not that it creates a statement that everyone can sign up to (but ultimately can’t remember), but rather acts as the guiding force behind the decision making within the PCN.  The vision tells us where we are going, and everything else we do should fall in line behind that.

This is why having a clear vision for the PCN is really important.  If we do not have a shared vision across our practices of why we are participating in the PCN in the first place, then we have no clear point of reference for our decision making.  In the absence of our own direction, we let the PCN DES itself dictate our actions.

The PCN DES is produced in a way that enables the general practice leaders that negotiated this additional funding and resources for general practice to justify the investment.  The additional £2bn that it brings has to come with an output, and so those in charge can point to things such as its contribution to the long term plan (the PCN DES specifications) and enabling general practice to work within the integrated care system.

But that does not mean that this has to be how it is used by practices.  While the contractual requirements are there, what practices need to do is work out how they want to make the most of the opportunity that it brings.  Practices can set their own goal or goals, and then the challenge is to work around the contractual requirements to achieve these goals, not simply provide what others want.

If you do not know what your PCN vision is, now is definitely time to take stock and consider what you want it to be.  If you don’t, you are defaulting to a position where others are effectively deciding what you do (because you are simply led by the PCN DES requirements).  Take the time to come up with more than a statement that everyone will agree to. Come up with what you all want to achieve, and that can guide your collective decision making and actions going forward.

23
mar
0

Should Practices Opt-Out of the PCN DES?

Posted by Blogs, The General Practice BlogNo Comments

April will mark one of the few opportunities practices have each year to opt out of the PCN DES. Is this a move GP practices should be considering, or do the benefits of staying outweigh the additional requirements on practices?

The lack of a negotiated contract for this year means the existing 5 year deal for general practice agreed by the GPC in 2019 rolls through into next year.  The response by the GPC has been a thinly veiled encouragement for practices to consider opting out of the PCN DES, “Should practices decide that they cannot accommodate the below changes, that their patients would be better supported outside of the PCN DES, that the practice would operate more effectively and safely outside of the PCN DES or any other reason, they are able to opt-out” (GP Contract Changes, BMA).

This theme is continued in the BMA’s recently published “Safe Working in General Practice”, which states, “There is an increasing view that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS staff… Practices will need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their wider practice, and their present workforce”.

This all feels somewhat disingenuous, and more of an attempt by the BMA to score political points over NHS England than genuinely putting the interests of practices first.

The reality of the 2019 deal and the introduction of the PCN DES is that it put an additional £3 billion funding into general practice, £2 billion via the PCN DES.  The majority of that funding has not yet come through.  We are only half way through the recruitment of the ARRS roles, the IIF funding has been limited due to covid and grows significantly over the next two years, and enhanced access brings £6 per head under the control of PCNs that previously in most places came nowhere near practices.

From a staffing perspective there are no new GPs, and whatever the promises (5,000 GPs, 6,000 GPs etc) there are unlikely to be any anytime soon.  The only way for practices to manage the ever increasing workload is to use different roles.  Notwithstanding the challenges of training, supporting and integrating these roles, they are the only realistic route for practices to find a way of managing the workload.  100% reimbursement (even if that doesn’t mean free) for these roles is not a bad deal.

PCNs are also the only route by which general practice can influence the newly developing integrated care systems.  The future NHS is not interested in any provider that wants to stand alone and not work in partnership with others.  If general practice wants to continue to be able to have a voice post-CCGs then it needs to work on how its PCNs can influence local arrangements.

The alternative is, as the BMA points out, to opt-put of the PCN DES.  This means practices will lose out on the PCN funding, the ARRS staff and worse, “NHS England is likely to transfer the funding, requirements and staff – likely via TUPE (Transfer of Undertakings) – to Trusts or alternative providers to maintain as much of the PCN DES as possible without general practice.” (GP Contract Changes, BMA).  Given the current Secretary of State’s penchant for nationalising general practice I am not sure the government would be that uncomfortable shifting PCN resources to acute trusts and making practices even more vulnerable going forward.

The only real rationale for opting out of the PCN DES is a protest vote because of the lack of any negotiated outcome to this year’s contract, which is what the BMA seems to be pushing for.  But any rational analysis of the situation shows that it is in practices best interests to stay in the DES and to continue to be able to access its (growing) resources.  That said it doesn’t mean things shouldn’t change.  As I have argued previously, in many places PCNs are too distant from practices, and not run with enough attention being paid to the sustainability of practices in mind.  Now is the time not for practices to opt-out of the PCN DES, but rather to ensure that the PCN DES, a part of the national GP contract, is playing its part in ensuring the future sustainability of the service.

16
mar
0

Where is the National Leadership of General Practice?

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The move into integrated care systems means the importance of GP practices in a local area working together to create a strong and united voice is greater than ever.  It is not easy, but in lots of areas PCNs, federations, LMCs and even CCG GPs are working out how they can set aside their differences in order to increase their influence in the new arrangements.  But why is the same thing not happening nationally?

There is a lot going on nationally around general practice right now.  The contract for 2022/23 has been issued without any agreement between the GPC and NHS England for the first time that many of us can remember.  I don’t think I have ever seen a clearer signal that a unified national GP voice is 1) needed and is 2) absent.

It is not only the contract.  The Secretary of State Sajid Javid clearly has some pretty radical ideas when it comes to general practice.  He happily wrote the foreword for a recent publication by think tank Policy Exchange that advocated for the end of the national GP contract and for practices to be nationalised.

We also have the Health and Social Care Committee chaired by Jeremy Hunt, and its Inquiry into the Future of General Practice.  There must be a danger that general practice is becoming a political football between the former and current Secretary of State, as they seek to score political points off each other.

Within this context the profession needs strong and united leadership.  I don’t mean union style demands for more (money, staff, support, GPs etc), as the landscape clearly requires a more refined political touch right now.  No sector, whether it is hospitals, community trusts or mental health providers, will succeed right now by framing what they need in isolation from the rest of the system.  Instead they need to demonstrate their contribution to the wider system, and how investment in them can play an important role in making the integration agenda a reality.

It is not hard to hear the acute trust voice advocating for themselves as large, functioning organisations to be the ones who should take general practice under their wing to create joined up pathways of care for patients inside and outside hospitals.  What general practice needs is not only leadership that will articulate the obvious fallacies in such a plan, but also be able to put forward compelling alternatives that build the role and influence of the service.

The problem comes in holding the support of frontline practices, many of whom want to hear their leaders demanding more, and at the same time operating within this political national environment.  Too often GP leaders will simply repeat the demand for more (see this response to the Policy Exchange report from the RCGP) in order to curry favour with practices, rather than because it has any chance of influencing anything.

National GP leaders need to start modelling behaviours for local GP leadership.  It would be great to see the GPC, RCGP and the GP leadership team at NHS England working together as a united group.  There are some very talented and capable individuals across these organisations, and they could work together to strengthen the national influence of general practice (which would be in sharp contrast to the void we have now).  Together they could find ways of both having an impact on how integrated care arrangements develop, and at the same time be able to take practices with them.

When the GPs at NHS England and the GPs in the BMA talk against each other, it is the service as a whole that suffers.  It doesn’t matter who is right and who is wrong.  In the present day context general practice needs to be united at every level, and we especially need that at a national level.  Surely now it is time to put organisational differences aside, and to start working together for the service as a whole.

 

9
mar
0

Guest Blog : What do the new Enhanced Access Requirements Mean for General Practice?

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Access remains a highly contentious issue and the latest publication from NHS England regarding the 2022/23 contract updates has resulted in a wave of concern from some GPs and unhelpful headlines in the usual suspects of newspapers.

Negativity permeates a lot of what we are doing as a professional sector and in many parts of society. It is easy to look at perceived problems and often hard to focus on the positives.

Of the Clinical Directors, PCN Managers and GP partners I have discussed this with, once we spent some time assessing the impact on them and their practices, it has been evident that this change is likely to bring about a number of positive outcomes. I wanted to share this with a wider audience to hopefully improve the perception of the changes.

Is there a greater time commitment?

If you are in a practice that has never delivered the Extended Access requirement and you have limited engagement with Improved Access it may feel like an increased obligation.

In most other cases it will be the same and, in some areas, could be a reduction of time. There are areas who have been working under Improved Access at or close to 45 minutes per 1,000 patients plus the 30 minutes of Extended Access. For these areas the strict obligation will be easier to provide.

Services I am involved with have been operating on a model of 37.5 minutes and in practice we have been delivering closer to 50 minutes under Improved Access at the request of our member practices. Consequently the new combined requirement will be between 7.5 and 20 minutes less than currently provided.

Many other areas are the same, but it is essential to ensure that the time requirement is tracked on a like for like basis.

Is there sufficient funding?

The letter states that NHSE will ‘bring together, under the Network Contract DES, the two funding streams currently supporting extended access to fund a single, combined and nationally consistent access offer…’. This means that for every patient £7.44 will be available.

Currently £6 per head is commissioned by the CCG and is paid to the local provider of Improved Access. Some PCNs took responsibility for this funding and commissioned their own Improved Access in 2020, others received the service indirectly through federations.

By moving this fund into the PCNs it is arguably the first significant funding stream that can significantly improve the performance and structure of the network.

The following table provides a quick reference to the new time obligations and funding to support it:

PCN Size Additional Minutes Additional Hours Funding per Annum Funding per Week
20,000 1,200 20 148,800 2,862
30,000 1,800 30 223,200 4,292
50,000 3,000 50 372,000 7,154
75,000 4,500 75 558,000 10,731
100,000 6,000 100 744,000 14,308

 

It is important to recognise that some of this money is already being used by practices and other funding will be with federations or other third parties. The effect of moving these funds into the PCN need to be carefully considered locally so it does not destabilise other services which may be relying on top slicing these revenue streams.

Will the workload increase?

The guidance is vague and in many ways that is far better than the current requirements managed by CCGs. One of the biggest challenges with Improved Access contracts was the focus on appointments of 15 minutes. This resulted in a limiting factor which either excluded or made it very difficult to count many of the more innovative uses of the additional time.

Group consultations, tissue viability clinics and DVT management clinics were some examples that delivered excellent patient outcomes but struggled to demonstrate the appointment counting criteria.

The new requirement simply states that the time is used for ‘any general practice services’. A narrow interpretation for this could be a full suite of services but I would recommend that unless further guidelines are brought out, we use a broad interpretation. Our focus will be on delivering those general practice services which are making the biggest impact on our patient’s needs and preferences.

In some areas this may be a full range of services in others it could be a focus on cohorts of patients. I am aware of a PCN who focuses on weekend clinics for the elderly as they discovered it was the best time for family and carers to help the patient travel to the practice.

This type of patient focused service modelling is at the heart of the original PCN concept and this is an opportunity to start shaping support around them. This is the first requirement in the preparation stages outlined in the guidance.

Sharing the workload between practices by developing shared services across the PCN should improve the levels of demand on practices if managed correctly.

Will much change?

For many practices probably not. Enhanced Access is not significantly different than the current arrangement and as argued above it provides new opportunities to PCNs in terms of service design, improved funding and integrating workloads.

The option remains for PCNs to take responsibility for the funding but to agree with practices and with other providers to continue providing existing levels of cover and services. As long as these meet the minimum requirements and the parties are happy with this approach this allows continuity whilst giving more financial control to the PCNs.

This may well be the stop-gap position whilst a longer term review and service redesign process is instigated by the practices to shape services in the future.

If you are in an area with poor service availability with current Improved Access providers, this situation should improve as you take greater control. There are also areas where the CCG top-sliced the £6 figure, so in these areas the full amount will be made available to practices for the first time.

There will be exceptions to this principle but in general this is a change which should be seen from a positive, pro-GP perspective.

Next Steps

We have until October before the new requirements go-live and first drafts of the Enhanced Access Plans need to be submitted by 31 July 2022. This time will fly by quickly so it is better to get started at the earliest opportunity.

It is likely that these plans will be subject to a form of localised template but in the meantime PCN teams can look at current arrangements, discuss with the practices how they want to manage the transition from the current service and speak with your current Extended Access providers.

You can also engage with your patients at the earliest opportunity. Use different data sources to build a picture of the changes that are most likely to improve services as a whole.

This information will be a great starting point to manage the transition to the new specification and you may be surprised about how little change is needed. For others this is a chance to start implementing some of those longer-term aspirations you have had and to start those service improvements which have been delayed in recent years due to the pandemic or a lack of funding.

It can be hard at times to be optimistic, but I am convinced from the discussions I have had over the past few days that this is a change that should be embraced rather than feared.

2
mar
0

What has the PCN ever done for us?

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There is a tension that sits at the heart of any PCN.  It is the mismatch between the practice expectation of a PCN (that it will support the practice and enable it to be sustainable at a time when GP practices are struggling), and the system expectation of it (that it will work as a force for integration at a local level and unite services around the needs of local populations).

This tension sits primarily on the shoulders of PCN Clinical Directors.  These individuals spend much of their time trying to engage their member practices in the PCN project, practices that are often asking the question of what the PCN has ever done for us.  At the same time the weight of system expectation is that they will form productive alliances with the local (sometimes failing) mental health trust to introduce mental health practitioners, or the local (under pressure) ambulance service to magic up new paramedics, or interface effectively with a whole regional infrastructure that drags the PCN social prescribers away from what the practices want from them.

What is the role of the PCN?  Is it to support member practices, and act as a vehicle for the introduction of additional roles that will sustain them in the absence of any more GPs?  Or is to tackle health inequalities and help ensure the needs of local communities that have often been overlooked finally start to be met?

The fundamental problem with the whole PCN agenda is that the answer to this question is not clear.  It feels like their introduction was a compromise, an attempt to try and do both of these things at once.  The problem is that it was sold to practices on the basis of their future sustainability (remember £1.8bn of the additional £2.8bn promised to general practice in the 2019 5 year contract was via PCNs), and at the same time sold to the system as providing the building blocks of the new integrated care system.

The problem with compromise is that it often means no one wins.  In social psychology studies of groups, compromise is considered lose-lose in a zero sum equation.  Both parties want 100%, but they both have to give something up to appease the other party.  As a result, neither party really gets all of what they want.  Typically it results in resentment and not really being happy.

This feels like where we are now.  General practice is not happy with the PCN DES, as was clearly signposted by the inclusion of resignation from it as part of the move towards industrial action.  At the same time the system is not happy with PCNs and the role they are playing in the developing integration landscape, or else why would they have been replaced by “neighbourhoods” in the recent White Paper?

This is all starting to feel like a missed opportunity.  There is no reason why PCNs cannot meet both agendas, and contribute to the sustainability of practices and enable meaningful local integration.  But what this requires is an explicit acknowledgement by all that PCNs are trying to do both of these things.  Their success should be measured by the extent to which it achieves both of these goals.

At present there is no marker of what PCNs have done for practices.  There is no reason not to make this explicit, and include it front and centre of what PCNs achieve.  At the same time the PCN DES measures that we do have are national markers (because it is a national contract) of the role of PCNs in integration.  But of course for them to be really effective in this role these measures need to be locally set – the challenges in Frimley are not the same as the challenges in Newham.

So instead of trying (badly) to do two different things for two different audiences, it would better for PCNs to be explicit about the dual goals to everyone, have appropriate separate measures for each, and be given the freedom to use the resources that are being made available to make both things happen.

23
feb
0

What the Integration White Paper means for General Practice

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The government published its White Paper “Joining up Care for People, Places and Populations” on the 9th February, describing itself as “the government’s proposals for health and care integration”.  This is apparently one of a set of reforms, as it sits alongside the Health and Social Care Bill and the Adult Social Care Reform white paper.

There is no getting away from the meaningless fluff that surrounds descriptions of integration in the paper (e.g. “Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole” p17).  The terminology within the paper is both over the top and (at best) confusing.

The paper clarifies (p18) that a “neighbourhood” is “an area covered by, for example, primary care and their community partners”.  You would think this would be called a PCN, but the PCN nomenclature appears to be have been dropped within this paper and replaced by neighbourhood.  A “place” is a locally defined geographic area typically 250-500k population, and a “system” is a larger area with a population of about 1 million.

In fact PCNs only get one significant mention in the paper, and that is primarily to signpost the fact that they are being reviewed, “GP practices are already working together with community health services, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as Primary Care Networks (PCNs). Building on existing primary care services, they are enabling greater provision of proactive, personalised, coordinated and more integrated health and social care for people closer to home. NHS Chief Executive, Amanda Pritchard, has asked Dr Claire Fuller (CEO Surrey Heartlands ICS) to lead a stocktake of how systems can enable more integrated primary care at neighbourhood and place, making an even more significant impact on improving the health of their local communities. This will report later in the spring.”

For a reason that I am not clear on, PCNs have shifted from being the central plank and foundation of integrated care systems, to something that contribute towards the overall ambition for integration – make of that that what you will.

The paper tries to distinguish between what will happen at the system level and at a place level.  There is the sticky issue of whether the NHS or Local Authority is “in charge” at a place level, and the solution the paper comes up with is that, “There should be a single person, accountable for shared outcomes in each place or local area, working with local partners (e.g. an individual with a dual role across health and care or an individual who leads a place-based governance arrangement).” p11.

However, “These proposals will not change the current local democratic accountability or formal Accountable Officer duties within local authorities or those of the ICB and its Chief Executive”, which does rather beg the question of what power or authority these newly accountable individuals will have.

The suggested governance model for place is via a ‘place board’, “a ‘place board’ brings together partner organisations to pool resources, make decisions and plan jointly… In this system the council and ICB would delegate their functions and budgets to the board” p34.

General practice therefore needs to work out how it is able to be an effective member of, and be able to influence, this place board.  This will inevitably require the PCNs within a place area to find ways of working together and to be able to create a unified voice.

The autonomy of these place boards is still open to question.  Despite a lot of rhetoric about the need for local areas to determine local priorities, the pull of the top down approach has once again proved too difficult to resist, “We will set out a framework with a focused set of national priorities and an approach from which places can develop additional local priorities” (p23).   A new set of national priorities is on its way for implementation from April 2023.  This means places will receive their must-do list which they will undoubtedly be heavily performance managed on, but of course can also set some additional priorities for themselves if they would like.

That said, the ambition remains for services and spend to be put under the control of place based arrangements, so I still think it would be wise for general practice to ensure it plays a central role within them.  One thing the paper is clear on is that general practice funding is not to be ringfenced from other spending, but rather included within a single system funding envelope (p36).

There are promises to have fully integrated shared care records across organisations and seamless data flows across all care settings in place by 2024, but if the last 20 years has taught us anything it is don’t hold your breath.

There is a whole chapter on workforce integration.  What is notable about this is more what it doesn’t say than what it does.  It talks about the pivotal role of link workers and care navigators in joining up care, about pharmacist integration, and about making better use of occupational therapists, but it never once references the additional roles coming into PCNs through the ARRS.

Overall the paper continues the national drive towards integration, and reinforces the need for general practice to make sure it is playing a central role in the developing place based arrangements for their area.  What is potentially of most concern is the shift away from the importance of PCNs and whatever lies underneath that.

16
feb
0

The Challenge of Being a PCN Clinical Director

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The role of a PCN Clinical Director is more challenging than it has ever been before, and yet we are about to see a huge turnover in those undertaking these roles.  Why is the role so different now, and how can those taking it on for the first time now even hope to be successful?

It may not feel like it, but it is now three years since we were first introduced to Primary Care Networks (PCNs).  They first appeared in the NHS Long Term Plan which was published in January 2019, which was then quickly followed up with the new five year GP contract the following month with the PCN DES for general practice.

After three months of set up, PCNs were formally established on 1 July 2019.  One of the requirements was that each PCN had a Clinical Director in place.  Many of these Clinical Directors agreed to take on the role for an initial term of 3 years.

Unfortunately the initial funding of 0.25wte per 50,000 population was wholly inadequate for the workload and expectation placed upon these new leaders.  This situation was not helped by the ongoing national refusal to make any funding available for PCN managers to lighten the burden on PCN CDs.  Whilst the funding has (belatedly) been temporarily increased to 1 wte and some (non-recurrent) funding has been made available for management support this year, it has never been done in a way that allows PCNs to invest more into PCN leadership on a permanent basis, or that enables those leaders to give up their other work and create more time for the role.

The PCN CD role has changed immeasurably in the last three years.  In their first year the (not insignificant) challenge was persuading practices to work together.  But since then PCN CDs have had to deal with Covid, the vaccination programme, a huge increase in staffing via the ARRS scheme, and an ever increasing set of delivery requirements, all during a period of transition into integrated care systems.

Let’s not forget, all of this has been set within a context of general unease across the service with PCNs.  At a number of points across the last three years there have been threats of widespread resignations from the PCN DES, and that threat is still hanging following the ballot from November last year.

It is no surprise, then, that many of those who put themselves forward to be a PCN Clinical Director back in 2019 are saying that enough is enough, and that it is someone else’s turn to carry the baton now that the initial three year term is up.

The problem is that most of these individuals have grown and developed with the role over the last three years.  They possess leadership skills and experience that they did not have when they started.  Their PCNs need them in the CD role now more than they ever did.  But the system has treated them in a way that means it is unsurprising that many do not want to continue.

And so we are in a position where in many PCNs, someone new, or maybe even two new people, are taking on the role.  The challenge for these new incumbents is even greater than it was for their predecessors because the roles are so much bigger now, and the expectations on PCNs are so much higher.

It will not be easy, and it will be down to both the local practices within a PCN and the local system to support this new wave of leaders so that they may also have a chance of success within the role.

It is with all of this in mind that myself, along with PCN CD Dr Hussain Gandhi and PCN expert Tara Humphrey, have set up PCN Plus.  PCN Plus is a development programme for those taking on the PCN Clinical Director role, and provides training for new PCN leaders in how to be successful in the role.  You can find more information about PCN Plus here.

9
feb
0

The Influence of General Practice on Integrated Care Systems

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The shift to Integrated Care Systems is going to be a difficult one for general practice.  The luxury of Clinical Commissioning Groups (whatever you might think of them) was that they put general practice at the forefront of decision-making.  Of course that is not really how they worked out in practice, but at least their existence ensured a strong presence for general practice in any system-wide decision making.

That, however, is all about to change.  It may well be that the statutory change to Integrated Care Systems and the formal abolition of CCGs is not due to take place until July, but these changes  are already being made and the new system will be up and running sooner rather than later.  The statutory representation of general practice falls to a solitary GP on the ICS Board, and they will have no requirement to be there in a representative capacity for the profession.

In a recent podcast with Dr Jaweeda Idoo from Greater Manchester, where devolution has accelerated the ICS agenda, it became clear that there are numerous levels between any individual practice and the ICS Board.  Each practice is in a PCN.  Each PCN works together with other PCNs in a “place” area.  The 10 place areas from across general practice work together in a general practice board for Greater Manchester.  Representatives from the general practice board are on the primary care board (incorporating wider primary care partners such as pharmacists, opticians and dentists).  Representatives from the primary care board sit on the Provider Board.   The full ICS Board then also includes CCG and Local Authority representatives.

There are a lot of layers.  The distance between a practice and the ICS seems vast.

In Greater Manchester general practice has retained a voice, but this seems to be due to the influence of certain individuals, such as Manchester LMC CEO Dr Tracey Vell, and a seemingly shared belief in the pivotal role general practice plays within the system.

But Integrated Care Systems are not being designed to maximise the voice of general practice.  Instead we have this sense of predatory hospital trusts, encouraged by the Secretary of State, considering how they can bring general practice under their wing and keep their needs central within ICS discussions.  Practices in areas more dismissive of the role of general practice than Greater Manchester may find themselves even further down the pecking order.

What, then, is general practice to do?  There is a school of thought that the only way to increase the influence of general practice is to make the service more relevant to the system discussions.  By doing more to impact the system, such as taking on outpatient and more minor procedures from the acute environment, or managing cohorts of the unwell at home, then it forces the system to listen.

There is another school of thought that general practice has not only react to proposals put forward by others (which appears to be the default system position), but must proactively generate ideas and strategies of its own in order to increase its sway in the discussions.  By bringing new things to the table general practice can create its own relevance.

While either of these things may or may not turn out to be true, my sense remains that the starting point has to be the development of a sense of unity and collective identity across general practice in any area.  At present general practice often feels divided between practice GPs, PCN CDs, Federation Directors, CCG GPs, LMC GPs, and even CCG primary care teams.  In the new system, however general practice chooses to work to generate influence, it has to do it together.  There can only be one general practice “team”, and everyone has to be on it.

For leaders in general practice preparing for the shift to Integrated Care Systems the most pressing priority right now has to be working to create this unity.  Divisions in the service sometimes run deep, but it is in everyone’s interests to put these to one side, to bring together all the skills and expertise that exist across the service, and work to unite these to give general practice the best possible chance of meaningful influence in the new system.

2
feb
0

Why Would Sajid Javid Claim to Want to Nationalise General Practice?

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On Saturday the Times reported a plan by Sajid Javid to ‘nationalise’ general practice.  It seems (once again) general practice has become something of a political football.  What are we to make of this latest report?

We need to put this latest development within the context of everything that has happened in recent months.  In October last year the government, clearly frustrated by complaints in the Mail and other elements of the press about challenges with access to a face to face appointment for a GP, pushed NHS England into the production of their document “Our plan for improving access for patients and supporting general practice”.

As a result the profession, already incensed by the lack of support from NHS England earlier in the year over the same issue, voted in support of a mandate for strike action.  Not, one would think, the response the government was looking for.

At this point (in November last year) the Health and Social Care Committee, now led by a transformed Jeremy Hunt seeking to use his position chairing this committee to undermine the government at any point, launched an Inquiry into the Future of General Practice.  Evidence for this inquiry can be submitted until this Friday, 4th February.

The Times article indicated that a review of General Practice is “planned” by Javid, so we can assume this is not the same as the Health and Social Care Committee Inquiry.  There are undoubtedly politics that we are not aware of between Hunt and Javid also at play, but what the Secretary of State certainly won’t want is Hunt’s Committee telling him what he should be doing with general practice.

The other important piece of context for this article is the wider shift to integrated care, and what this means for general practice.  As I discussed a couple of weeks’ ago, the Planning Guidance for the NHS seems very geared towards the role general practice can play in support of acute trusts, in particular in relation to the rollout of thousands of virtual wards.

A review of PCNs was also announced in November last year, and interestingly this review is now framing itself in terms of what “integrated primary care” looks like.  In this video the leader of the review Clare Fuller does not reference PCNs once.  This review is due to report next month, so it is not beyond the realms of imagination to think that this is the review that Javid is referencing in the Times article.

This would also explain the timing of the article, although of course all this is being carried out at exactly the time that the newly elected GPC committee, armed with their strike mandate, are negotiating the first contract.  This government, for longer than most of us can remember, wants better access to a GP above all and everything else, and if negotiations are not going well this might be the perfect time to threaten nationalisation to move things along.

The argument for organising health services around the needs of hospitals (as opposed to the health needs of the population) is so antiquated that it is hard to believe that it is being taken seriously.  That said, with this government anything is possible, and there are disturbing trends within Integrated Care Systems and the guidance around them towards creating primacy for the needs of hospitals.

But overall my sense is that general practice has very much become a political football, and that most of this is political game playing.  I don’t really think Sajid Javid wants to nationalise general practice, and to end up in a full on dispute with the profession, but I think there are things that he does want and reports like this are simply a means to help him get them.

26
jan
0

5 Things to Watch Out For in 2022

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What is on the horizon for general practice in 2022?  Here are 5 things to watch out for in the year ahead.

February: Contract Negotiations.  We are three years in to the 5 year deal agreed in 2019, so you would think that contract negotiations this year would be relatively straightforward.  However, once you throw in Covid, the government’s concern with GP access, a new GPC leadership team, and the vote in support of industrial action made by the profession at the end of last year, the negotiations this year could well be a spikier than normal affair.  Despite the profession’s reaction there has been no softening of the national stance on GP access, and so it will be very interesting indeed to see what comes out of this particular set of negotiations.

March: PCN Review Report.  In November last year a review of PCNs was announced, and how “they will be working with partners across newly formed integrated care systems”.  Potential concerns were highlighted at the time, namely that it implied a need for more national control over PCNs, that it could signal a shift of ownership of PCNs away from practices, and that it may very well further distance PCNs from the pressing issue of general practice sustainability.  This report is due in March, most likely coinciding with whatever comes out of the contract negotiations, and there is a good chance it will have big implications for general practice.

June: 3 years of PCNs.  It may only feel like yesterday but in June it will be three years since PCNs were first established.  PCNs now, with their large team of additional role staff and increasing set of delivery responsibilities, are significantly different from what they were back in 2019.  However, three years may also mark the end of the tenure of many of the initial PCN clinical directors.  While we have experienced some turnover of CDs already, this year could well see a much a greater turnover with many coming to the end of the term they initially agreed, and taking on the role may prove a tough challenge for those coming new into the role this year.  How this affects PCNs as a whole is something only time will tell, but unless more support is put in place it is unlikely to be positive.

July: Integrated Care Systems go live.  It feels like we have been living in the shadow of integrated care systems for some time now, but (according to the new planning guidance) they will finally go live in July this year.  This means CCGs will formally be abolished, and general practice will be left to fend for itself amongst the other providers as we all ‘work together’ to agree how care is organised and how resources are divided.  The extent to which general practice can influence and impact these new systems may well be very important in determining the level of local investment and support in the service going forward.

October: Shift of Extended Access to PCNs. Well, maybe.  This shift was supposed to happen in April last year, and then in April this year, and now in October this year, and the continual delays do raise the question as to whether this shift will ever really happen.  But if it does it may well spell the end of financial sustainability for the significant number of GP federations that rely on this funding, and this in turn could well create difficulties for both local practices and PCNs.  It is an issue that when the guidance (finally) comes out will need some working through to ensure we don’t end up with more problems than we have now.

19
jan
0

What this Year’s Planning Guidance Means for General Practice

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Each year the NHS publishes planning guidance.  This year is no different, and on Christmas Eve (happy Christmas everybody…) true to form the NHS published “2022/23 Priorities and Operational Planning Guidance”.   It outlines for the NHS what needs to be achieved in the year ahead.

While it is not a document specifically aimed at general practice (rather it is aimed at the NHS as a whole), it provides an interesting perspective on how general practice is viewed within the system, what the priorities for general practice are likely to be, and gives some indication as to what will feature in next year’s GP contract.

The document sets 10 priorities for the NHS.  General Practice explicitly features in one of them, namely to, “Improve timely access to primary care – maximising the impact of the investment and Primary Care Networks (PCNs) to expand capacity, increase the number of appointments available and drive integrated working at neighbourhood and place level” (p6).

So first off, in case anyone thought there might be some national backing off from the October guidance that generated such a backlash (including a mandate for national strike action for the GPC), there is a clear reinforcement of the need for the paper to be implemented (“In line with the principles outlined in the October 2021 plan, systems are asked to support the continued delivery of good quality access to general practice through increasing and optimising capacity, addressing variation and spreading good practice” p25).

More interesting is the newer theme that pervades the text around integration.  Integrated Care Systems go live next year, although this document confirms that this will now happen on July 1st not April 1st to allow time for the bill to pass through parliament.  Systems are exhorted to, “maximise the impact of their investment in primary medical care and PCNs with the aim of driving and supporting integrated working at neighbourhood and place level.  Systems are asked to look for opportunities to support integration between community services and PCNs” p24.  The review of PCNs will be reporting in March, and I wouldn’t be surprised if it marks a shift of PCNs away from ownership solely by practices.

Systems will also be judged by the extent to which their PCNs have made use of their ARRS allocation, and are also asked to support employment models across organisations, “Systems are expected to support their PCNs to have in place their share of the 20,500 FTE PCN roles by the end of 22/23 and to work to implement shared employment models” (p24).  It is interesting that underneath the opportunity for PCNs to use the ARRS funds there is a top down pressure on local systems for all the money to be spent.  Indeed, the rationale used is not to support general practice, but “to support the creation of multidisciplinary teams” (p9).

There is a further notable nuance that PCNs (not practices) are treated as the unit of general practice in the guidance.  It claims that there will be, “ a suite of national GP recruitment and retention initiatives to enable systems to support their PCNs (not practices) to expand their GP workforce and make full use of the digital locum pool” (p9).  We also won’t hold our breath in anticipation of all the same additional GPs we have been promised for the last 5 years…

There are two other major items of note for general practice in the guidance.  The first is the big push in the guidance on the roll out of virtual wards.  The ambition set is that by the end of 2023 there will be 40-50 virtual wards per 100,000 population.  These are to be based on a partnership between secondary, community, primary and mental health services, and they “should only be used for patients who would otherwise be admitted to an NHS acute hospital bed or facilitate early discharge” p21.  £200M in 22/23 and £250M in 23/24 is being made available to develop these wards, although given the numbers of wards expected how they will work is a mystery, as my back of the envelope calculation gives each ward less than £10,000 to operate.

The other item of note is a promised new IIF indicator for PCNs to incentivise contributions to a minimum of 2 million additional pharmacy consultation appointments in 2022/23.  According to the guidance (p25) this will move “more than 15 million appointments out of general practice”!

Overall, the main takeaway is the pressure that will come around ‘integration’ – PCNs and PCN staff to work across organisations, multidisciplinary teams, multi-organisational virtual wards, joint working with pharmacies, and (of course) new integrated care systems in charge of everything.  What could possibly go wrong?

15
dec
0

2021: The Most Challenging Year Ever?

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2021 has been quite a year.  What can we takeaway from everything that has happened, and where are we now as move towards 2022?

The year started with the vaccination programme (in a way hugely reminiscent of everything that is happening right now).  When things were critical, and a fast response was needed, it was general practice that the NHS (and the government) turned to.

For the first months of this year, the vaccination programme was exhausting.  There were real concerns that the programme would prove to be too much for general practice.  One GP predicted at the time, “Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (here).

While we didn’t end up with mass resignations, there was certainly a withdrawal from the programme by many because the constant demands were proving simply too much.  And when the delivery demands of general practice as a whole were increased in April, despite the ongoing demands of the vaccination programme, it did raise the question of who is looking after general practice?

No one, it transpired.  As complaints from the worried well emerged via sections of the press, rather than defend the over and above contribution already made by the service NHS England responded with a letter in May mandating practices to offer face to face appointments.  Understandably, this did not go down well.

Despite some huffing and puffing, at the time no real response was made by the service, much to the consternation of many.  But a few months later NHS England’s publication on improving access and “support” for general practice (essentially how they were going to performance manage practices into offering more face to face appointments) proved to be the straw that broke the camel’s back.

By this point the demand on the service had become so great that the model of access to general practice now required a virtual or telephone triage to protect the face to face appointments for those who really needed them.  Instead of supporting the use of this model, and helping to explain it to the wider population, ministers and NHS England spent time on national TV promising anyone who wanted a face to face appointment with their GP that they could have one.  Nothing could have been either less helpful or more incendiary.

As a result the BMA balloted on industrial action, and supported by the service it now has a mandate to take into next year.

The other big development in 2021 was the shift of the whole systems towards integrated care, as a replacement for the historic commissioner provider split.  The White Paper was published in February, and while it is still making its way through parliament the NHS has been moving at pace to be ready for its approval and it becoming legislation.

It has been a challenge trying to work out what the new system means for general practice.  Design guidance followed for the service in June, and we started to understand the importance of local place based arrangements for general practice, as well as the role of PCNs in representing practices in these models.

The big concern is that there will be a loss of influence for general practice.  While CCGs are (supposed to be) GP led, there is no such requirement of integrated care systems.  Indeed the formal role of GPs in the new arrangements is relatively limited, and leadership of the new system by general practice feels unlikely.  But, as ever, general practice has worked its way through the issues, and areas have worked out that by PCNs, federations and LMCs coming together general practice can have the strongest voice in the new system.  The overall strategy needed is one of pushing decision making to the most local level possible, working together to create a single local voice for general practice, and then using this voice to influence decision making locally.

Here we are at the end of the year, with the service feeling very much on the precipice.  Integrated care systems are due to go live during 2022 (dependent on when the legislation finally gets approved), industrial action looms (one assumes depending on the outcomes of contract negotiations early in the new year), and covid is fighting back to add yet more pressure on to the service.

We have now come full circle with a new call to arms for general practice to once again lead the vaccination charge for the country.  Let’s hope next year there is both more appreciation for the critical role general practice plays, and more support for the service to recover from what has undoubtedly been one of its most challenging years ever.

8
dec
0

GP Partner Training – the Learning So Far

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Earlier this year myself and a group of colleagues decided that we should put in place the training for new GP partners that we had been talking about for such a long time.  The course finally started in September of this year, and we have already learnt some interesting lessons along the way.

I teamed up with Tara Humphrey, PCN management expert, Director of THC Consulting and presenter of the Business of Healthcare podcast; Robert McCartney, general practice governance expert and Director of McCartney Healthcare Associates; Dr Naj Seedat, GP, trainer, partner in a large North East London practice and LMC Chair; and Dr Farzana Hussain, GP, GP appraiser, mentor, trainer and lecturer.  Together we formed a really strong team, designed to be able to meet all the development needs of new and aspiring GP partners.

We designed the course into 20 sessions, broken down across three broad areas: understanding the business (i.e. what goes on within the practice); understanding the environment (i.e. what is happening around the practice that affects it); and understanding the risks (i.e. how do you build a strategic plan for the future).  Naturally the weighting of the first area is greater than the other two, as there is so much within the business of a practice for any new partner to get their head around!

We wanted the course to not be too demanding on GP time, which is why we went for the model of an hour a fortnight over a period of 9 months.  This has worked to the extent that it has made the course manageable in terms of time for participants.  The challenge, however, has been how to cover such huge topics as managing people or understanding premises in just an hour.

We have been working hard to do this well, but for some topics we just had to extend the sessions.  For example, when accountant James Gransby ran the session on understanding the practice finances we had to make the session an hour and a half.  Even then it was hard to cover everything for such a complex topic!

The other challenge we have experienced is how to make the sessions interactive when there is so much content to work through.  In an hour the scope for really interactive sessions is limited, but at the same time the more interactive the sessions are the more valuable they can end up being for participants.

Another lesson we have learned is that one of the biggest challenges new partners experience is taking on the role as a business owner and what this means in terms of how they lead and manage staff.  This is a really critical area for GP partners, as their leadership style really affects the culture of the whole practice.

As a result of all this we have made some changes to the programme, for the next cohort of new or aspirant GP partners who will be joining.  In the new format content will be delivered over six monthly half day sessions.  This will allow us to create longer, more interactive sessions where we can tailor the content to the specific needs of those on the programme.

We have also included core strengths training as standard, as it really helps new partners understand and develop their leadership style, and given over a whole half day session to leading and managing people.

We always knew developing this training would be a journey, and that we would be learning as we went along.  We are delighted with how the programme is going so far, and excited to make the changes to make it even better going forward.

The programme for our next cohort commences on the 1st February 2022.  We still have some places remaining, so if you or someone in your practice is interested you can find all the details here.  Alternatively get in touch and I am happy to talk through individually what we are doing so that you can work out whether it is right for you – I’m ben@ockham.healthcare.

1
dec
0

50 to 1

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I am spending some time working with a number of areas thinking through how to create and develop a strong, unified voice for general practice, that can be effective and influential within the new integrated care landscape.  It is a challenge that is harder than it sounds.

The problem comes because “general practice” in any given area generally consists of about 50 different, independent, autonomous organisations.  There are the 40 or so individual practices, 5 to 10 PCNs, maybe a federation, and the LMC.  How do you get 50 organisations to speak and act with one voice?

There is a framework that is quite helpful to consider in this context, called the Cynefin Framework.  Essentially it breaks problems down into different categories.  For our purposes what is helpful to understand is that there is a difference between simple, complicated and complex problems.

Simple is a problem that has a relatively straightforward solution, such as how do I lower my car window.  There is a specific, straightforward answer (press the right button).

Complicated is a problem that does have at least one solution, but which can be difficult to deliver.  An example that is commonly used is sending a rocket to the moon.  It is not a simple thing to do, and may well require multiple teams and specialised expertise.  But by really effective project planning, and using the experience of those who have done it before, it is possible to create a path to making it happen.

Complex problems are ones that are impervious to a reductionist approach that strips the problem (however complicated) down to its core components to work out the solution.  The example commonly used is raising a child.  There is no handbook because each child is unique.

For a complicated problem you can use a project planning Lewinian style approach to solving it.  But for a complex problem the approach needed is an emergent one, using trial and review (like PDSA cycles for you NHS improvement fans, or probe, sense and respond which Snowden, who introduced the Cynefin framework, uses).

This distinction is useful because in healthcare we commonly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches.  We look for business cases with defined outcomes as a default mechanism for moving forward, when this approach can only work for something that is simple or complicated, not for something complex.

Back to our problem.  How do we get 50 general practices organisations to operate as 1?  It is a complex problem.  There is no handbook, because everywhere is different.

That is not to say it is impossible.  What we can do, even operating in the domain of emergence, is understand what factors we need to build in order to give ourselves the best chance of success.  Two stand out.

The first is the need to build some capacity and capability at the collective general practice level.  If general practice is trying to operate as one then whatever forum or entity is trying to bring it all together needs to develop the ability to do a number of things.  It needs to be able to communicate with its 50 organisations.  It needs to be able to coordinate activities across those organisations.  It needs to be able to interact effectively with partner organisations.  These things don’t happen because the different parts of general practice simply meet together.  They need to put in place.

The second is the need to build trust.  Trust is the key ingredient.  If the 50 organisations don’t trust the 1, all is lost.  Here we get into the area of the prisoner’s dilemma, which explains why rational actors won’t cooperate even when it is in their best interest to do so.  Just because it makes sense for general practice to create a single unified voice it doesn’t mean they will do, and in fact without trust it is much more likely that they will not.

It is particularly challenging in general practice because we are all so instinctively independent.  That is why we have 50 different organisations in the first place.  We hate our independence and ability to act autonomously being in any way compromised.  We find working in PCNs difficult enough.  We instinctively pull away from any notion that we might get into scenarios where our practice or PCN has to act for the greater good rather than simply what is best for our practice or PCN.

As we move forward with the 50 to 1 challenge, our approach then needs to be an emergent one, i.e. one where we try things, see how they work, and then adjust accordingly.  We need to keep our eyes on the outcome (why are we doing this), and work hard to build trust and create some capacity and capability along the way.  It might make plan writers uncomfortable, but it is the way forward that will give us our best chance of success.

24
nov
0

The Inquiry into the Future of General Practice

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The Commons Health and Social Care Committee has announced a review into the future of general practice.  What does this mean, why would they do this, and what are the implications for the service?

The Health and Social Care Committee is a cross party committee charged with overseeing the operations of the Department of Health and Social Care and its associated agencies and public bodies (including NHS England).  It essentially has a scrutiny role.

The Committee chooses its own subjects of inquiry, which it then undertakes by reviewing written and oral evidence.  Once complete, the findings of the inquiry are reported by the Committee to the House of Commons.  The government then has 60 days to reply to the Committee’s recommendations.  The government does not have to accept them, e.g. the Environmental Audit Committee inquiry into disposable packaging recommended a 25p “latte levy” on disposable coffee cups; but the government rejected it, preferring for coffee shops to incentivise customers by offering discounts for the use of reusable cups.  However the cross party nature of the Committee, designed to build consensus across parliament, means its recommendations do still exert considerable influence.

This committee on the 16th November launched an inquiry into the future of general practice.  Its headline focus is to examine both the challenges facing general practice over the next 5 years, and the biggest and current barriers to access to general practice.  The committee is actively seeking evidence from anyone with expertise in the area (i.e. you, if you are reading this).  The deadline for submissions, which must be no longer than 3,000 words, is Tuesday 14th December.

It is one of 9 current inquiries the Health and Social Care Committee either has underway or that are complete and are awaiting a government response.  The others are workforce burnout, lessons learnt from coronavirus, children and young people’s mental health, treatment of autistic people and individuals with learning disabilities, supporting those with dementia and their carers, cancer services, clearing the backlog from the pandemic, and NHS litigation reform.

The inquiry into general practice will cover a range of issues (you can find the full terms of reference here), but it includes regional variation in general practice, general practice workload, and the partnership model of general practice.  The specific question in relation to the latter of these points is, “Is the traditional model of general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?”.   There is also a question about PCNs, “Has the development of PCNs improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?”.

What can we make of the announcement of the inquiry into the future of general practice?

The first point to note is the timing of the announcement.  It has come at a point where there has been considerable media and public attention to the challenges around access to general practice, and is also hot on the heels of the announcement of a ballot for industrial action of GPs by the BMA in response to NHS England’s recent publication on improving access and support for general practice.  It does not seem unreasonable for this to have been picked up as a point of concern by the Committee at this point in time.

The second point to note is that the Chair of the Health and Social Care Committee is Jeremy Hunt.  Jeremy Hunt appears to be enjoying his role as a backbench GP, able to chair this committee from a position of considerable knowledge, particularly in terms of how he can make life as uncomfortable as possible for the government.  His own response to the NHS England document was that it “won’t turn the tide” for GPs, and this seems to be reflected in some of the wording of the terms of reference, e.g. “to what extent does the government’s and NHS England’s plan for improving access for patients and supporting general practice address these barriers” (to access to general practice) when it is already clear to everyone that it does not.

There will be the more cynical who assume this is a back door attempt to end the independence of general practice and shift practices into the main body of the NHS, or conversely to privatise things further by shifting all remote and telephone consultations to digital first providers to “reduce pressure” on practices.  And while it does seem odd to want to look at the partnership model of general practice only a few years after the 2019 review by Nigel Watson, the cross party nature of the committee, along with the methodology of collating evidence from as wide a group of experts as possible, does make this seem unlikely.

Whilst it is hard for anyone in general practice to trust anything led by Jeremy Hunt, my sense is the best course of action would be for as many of those working in general practice as possible to give evidence and provide their views on the questions asked and what is needed going forward.  It feels like a genuine chance to be heard, and is a welcome change from the recent policy directives received from NHS England which have had little or no consultation at all.

17
nov
0

3 Reasons to be Concerned about the Newly Announced Review of PCNs

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The NHS announced last week that  they would be undertaking a review of primary care networks and how they will “work with partners across newly formed integrated care systems to meet the health needs of people in their local areas”.  The review will report by March 2022, ahead of ICSs going live as statutory bodies.  Whilst it might all appear very anodyne on the surface, it does set alarm bells ringing.

There are three reasons for concern.

  1. The perceived need for greater national direction

What the announcement of the review signals is that NHS England, in what is now customary NHS England style, is seeking greater control over PCNs and how they operate.  The initial language used around PCNs was that they how they operated was for local determination by local practices to best meet the needs of local communities.

That, however, now appears to be going out of the window.  NHS England clearly wants to set more guidance and rules on PCNs and how they work.  The contractual constraints of PCNs are already suffocating for many, and so it is hard to see how extra national directions will be helpful.

What we have with this review is a signal that someone somewhere high up is not happy with how PCNs are progressing, and has put this review in place to change where they are headed.  This review has also been announced hot on the heels of the BMA motion for industrial action and mass resignations from PCNs.  This may be unrelated, but it does lead on to my second concern.

  1. It signals a shift in ownership of PCNs away from practices

If you read the announcement from NHS England you will notice it has a very clear focus on joint working.  It talks about how PCNs “will work with partners”, how they can “drive more integrated primary, community and social care services at a local level”, how they can “bring partners together at a local level” etc etc (it carries on like this throughout).

If you recall when PCNs were first announced there was quite a number of references made to how PCN Boards would be expanded over time to be more than simply the member practices.  Whilst some PCNs have widened their PCN Board membership, most have not.  Given the language in this announcement it would be astonishing if the recommendations made were not about a shift of PCN ownership away from practices and towards a much wider ownership.

How far-fetched is it to suggest that this report will end up “recommending” a place for councils, community trusts (and no doubt others) on PCN Boards? Maybe a direct accountability into place-based partnerships will be imposed on them.  Whatever comes, it is hard to envisage a positive outcome of this review for practices.

  1. It further widens the gap between PCNs and the sustainability of general practice

At a critical point in time, just over half way through the 5 year GP contract that introduced PCNs, when general practice has reached such a desperate place that it is prepared to consider strike action, this review is announced.  In the announcement general practice or GP practices receive only one mention, and that is about the need to improve partnership working between GP practices and other organisations.

This report will not be looking at how PCNs can better support the sustainability of GP practices, despite the majority of the additional funding for general practice coming via PCNs.  It is hard not to see the announcement of this report as part of NHS England’s response to the GPC’s threat of industrial action, and if it is it spells more bad news for general practice.

I am not generally a pessimist or a conspiracy theorist, but everything about this report sets alarm bells ringing.  Time will tell whether these are unfounded concerns, or whether it is the first signal of yet more challenges to come for general practice.

10
nov
0

Is General Practice Making the Most of the Opportunity of PCNs?

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It is a difficult time for general practice right now. The pressures of workforce and workload are higher than ever, exacerbated by the media and their impact on patient expectations and overall morale.  How can general practice move forward?  How can it shift from the place that it is now into a more sustainable future?

In 2016 the GP Forward View, a 5 year “rescue package” for general practice, announced an extra £2.4bn for general practice by 2021.  This was then somewhat usurped in 2019 with the new 5 year GP contract that announced an additional £2.8bn for general practice by 2024.

What we have known for a while is that more resources on its own are never going to be enough for general practice.  We don’t feel £2.4bn better off than five years ago.  The reason for this is the growth in resources will never be able to keep up with the growth in patient demand and expectations.  There need to be changes alongside the resources.  These changes need to be in how we manage demand and how we organise ourselves.

Here we get into problems.  No one really likes change.  Look at how certain sections of the public and the media have reacted to changes to the management of demand in general practice where only those who actually need to be seen (as opposed to those who want to be) are seen face to face.  Whether the government likes it or not we will end up there, but it helpfully reinforces the point that no one likes change.

When you examine what options are available for changes in terms of how general practice organises itself (which we did in our 2016 book) they are broadly around staffing, operating at scale, using technology and working in partnership with other organisations.

This is where PCNs come in.  What stands out for me about PCNs is that they offer an opportunity for practices to be able to make virtually all of these changes, and to be able to do so in a way that protects the independent contractor model.  Prior to PCNs it was all about mergers and super practices, but what PCNs do is provide a construct that allows practices to access the benefits of scale while at the same time protecting their own individual identities.

But delivering the potential benefits does not happen by itself, or as a function of signing up to the PCN DES.  It requires practices within a PCN to commit to using the PCN construct to drive change in the way the practices operate to realise the benefits.  Change does not become easy because you call it a PCN.  It remains difficult, but what PCNs provide is a framework for practices to use if they choose to do so (in addition to providing a huge source of resources – £1.8bn of the additional £2.8bn announced in 2019 is coming via PCNs).

I have no idea whether this was the original idea behind PCNs.  I suspect it wasn’t.  Certainly the contractual nature of PCNs, the tick box style of the IIF, the push to recruit more and more new roles with hardly any support for transformation alongside these roles, and the continual attempts by the system to hijack the PCN agenda are not conducive to practice transformation.  But at their core PCNs do provide practices with the chance to broaden their staffing model to reduce the pressure on the GPs and to build relationships with other practices and other organisations to create shared service models that work better for everyone.

However, at present it feels like PCNs are an opportunity for general practice that is not really being grasped.  Many practices choose to keep PCNs at arm’s length.  The BMA is trying to use PCNs as a mechanism for pressuring government and NHSE.  Others want to use PCNs for their own ends.  But PCNs are a huge, well-resourced opportunity to make change that can be a huge force for good and for creating a positive future for practices.  Practices just need to choose to take it.

3
nov
0

Should PCNs be Political Footballs?

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Two weeks ago the BMA reported that it had rejected what it terms “the government’s rescue package” and that it was to take a ballot with the profession on industrial action.

The specific motion passed by the GP Committee contained two clauses directly pertaining to PCNs. It:

ii. calls on all practices in England to pause all ARRS recruitment and to disengage from the demands of the PCN DES
iv. calls on all practices in England to submit undated resignations from the PCN DES to be held by their LMCs, only to be issued on the condition that submissions by a critical mass of more than 50% of eligible practices is received

What does this mean for PCNs?  There are effectively three requests being made of practices in relation to PCNs.  The first is to pause ARRS recruitment.  Unfortunately ARRS recruitment is the one part of the PCN DES that many practices consider to be value adding.  Whilst there are some whose primary concern is the clinical supervision, line management and estates challenges these roles can create, increasingly practices are able to realise the benefits of these additional staff on their workload and outcomes for their populations.

It is hard to understand how sending a message to practices and PCNs to stop recruitment into these roles, the one thing that is helping with overall workload, is helpful in the current context.  Do we think that collective pausing of recruitment for a few weeks or months will influence the government/NHS England?  The downside of the suggestion seems far more detrimental than any potential upside.

The second is the call for practices to disengage from the demands of the PCN DES.  There is an anger amongst many that the delivery expectations on PCNs have been ramped up so steeply from October 1st.  The number of IIF indicators (the ‘PCN QOF’) has gone up from 6 to 19 for the last six months of the year, along with a requirement to deliver against two additional DES specifications (health inequalities and CVD prevention and diagnosis).  Disengaging will, however, potentially cost the practices of an average PCN £120k (what they could earn through delivery of the IIF indicators, which are also linked to the delivery of the two specifications).

The third is the submission of undated resignations from the PCN DES by practices. This suggests that the reason practices participate in the PCN DES is because they want to support the government’s/NHS’s desire for PCNs to exist.  In reality there are two reasons.  The first is that PCNs make sense financially for practices, and the second is that practices believe that by working together as a PCN they can improve outcomes for patients.  While the initial decision to sign up was probably more for the former reason, as time has gone by more practices believe they can make a difference through their PCN.

The request, then, is for practices to sacrifice the benefits they receive and believe can be achieved for their patients in order to derail the wider national plan in relation to PCNs, to build influence in the debate on the issues of concern (i.e. the failure to address the crisis in general practice, the recently published plan around access, the GP earnings declarations, and for GPs to oversee the Covid vaccination exemption process).

I understand the desire for greater negotiating power.  The cost, however, falls on PCNs themselves.  While PCNs have been working hard to build trust across their practices, to create ways of working that benefit all, and to make a difference both to practice sustainability and patient outcomes, the effect of something like this is to set the whole thing back.  It makes it easier for the practices that have never really engaged to not do so, and makes it even more difficult for those who have been working hard to realise the benefits of joint working, because now the spectre of mass resignation can sit as a rationale for inaction.

So is it worth it?  Is the threat around PCNs worth the problems this causes to practices?  The Guardian reported that the BMA had won “significant concessions” from NHS England following its threat of potential industrial action.  These included the plan to publish ‘league tables’ – showing what proportion of appointments were in person – had been abandoned, along with specific targets.  However, the organisation seemingly responsible for setting policy in relation to general practice, the Daily Mail, reported that the Department of Health had moved quickly to insist it had made no concession to doctors’ unions, and that it would press ahead with measures to publish surgery-level data on face-to-face appointments.

Time will tell how this will all play out.  I fully support the push back by general practice to the NHS England paper on access, which was the NHS operating at its very worst.  However, I worry that not enough thought has been put into the consequences of conflating PCNs into a dispute that is not actually about PCNs.  Doing so is effectively self-harming for the service, and in particular it has left those in PCN Clinical Director roles, who are arguably doing the most for general practice right now, in a very difficult position indeed.

27
oct
0

GUEST BLOG: Dr Rachel Morris – 3 Conversations You Should Be Having With Your Overwhelmed Teams Right Now

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Many of our team members in Primary Care are feeling battered and bruised by the tone and content of what’s coming out from on high, and everything going on in the media. As a leader you may feel frustrated and angry yourself, and you may be wondering just what you can do to help everyone keep on going through these really tricky times.

There are three key questions which will help you and your team to take stock of what you can do about the situation, work out what you should be prioritising and reduce some of the stress and anger about what’s going on.

 

What can I control?

The first question is all about what is in your power to change, and what’s not.

In any of life’s challenges, there are things which we worry about which we simply can’t do anything about (for example, rising COVID rates, government policy, the national shortage of GPs). Dwelling on these things is a waste of precious time and effort as there is literally NOTHING that you can do to change them.

A far more productive way to spend your time and mental energy is to ask yourself ‘what is in my control right now?’. A simple way of doing this is to do the ‘Zone of Power’ exercise.

Get a sheet of A4 paper, draw a circle – this is your zone of power. Outside the circle list all those things you are not in control of, and inside the circle list all the things which you ARE in control of, and the options and choices which you have. You may not like all of these options and choices and you may feel frustrated about the consequences of some of these choices, but you will feel more powerful and productive by focussing on what you CAN do rather than what you can’t.

The key to this exercise is learning to ACCEPT the things you can’t change and find the COURAGE to change the things you can (this will also help you with the WISDOM to know the difference – sound familiar?!).

Use this question with your team members whenever any of you feel stuck, to work out what your next actions could be.

 

Where is your focus?

The second question helps teams get super clear about what your priorities should be right now.

Many teams in primary care are feeling overwhelmed and exhausted. There are too many things to do and not enough time or staff to do them. But do you know exactly what these things are? Have you had a conversation about what you should be prioritising as a team, as a practice, as a PCN?

So often, we see team members with different priorities going in different directions which causes confusion and overwhelm as no one really knows which is the most important priority, and what they can drop for now. Without this conversation, the stuff that’s urgent will always crowd out the stuff that’s really important but perhaps not urgent – yet, such as team development, sorting out workflows, delegation and staff training.

Getting clear on what three things you will be focussing on as a team in the next week, month and year will help reduce overwhelm, create some mental headspace, and make sure you’re all laser focussed on the same things.

 

What story are you telling?

As patient demand and expectation seem to grow every week and negative stories in the media threaten to kill our morale stone dead, it’s helpful to ask yourself ‘What is the story in my head’ about the things that are bothering you.

When patients are rude and demanding, do we tell ourselves that’s because they are completely unreasonable, that they all hate us and that we’re doing a terrible job? Or do we recognise the truth – that patients may be frightened and worried about themselves (after all, we are going through an incredibly traumatic time as a planet), they may be frustrated that they can’t get exactly what they want instantly (in a world of Amazon Prime and Netflix).

Do we tell ourselves that we are failing and not good enough? Or that Primary Care is doing an AMAZING job in the face of huge challenges, and that we are doing our absolute best through difficult times?

Are we telling ourselves that it’s us vs “them”. Or that we are all actually on the same side, wanting a properly funded, safe and efficient primary care service in which staff AND patients are thriving?

Are we telling ourselves that we ‘have’ to do it all, can’t take any time out or that saying ‘no’ makes us a bad person? Or are we recognising the truth that it’s only by putting our own oxygen mask on first, recognising our limits, and taking time to rest and recharge that we will do our best work?

The stories we tell ourselves create feelings which lead to actions. The negative stories we tell can only lead to stress, disillusionment and often keep us stuck and frustrated. By re-framing what we choose to believe (but not denying the reality of the difficulties) we can start to change our feelings and actions and reduce the stress and levels of burnout we experience.

These are simple questions, but they are not easy. They require a degree of self-examination and recognition of some difficult truths BUT if you start to ask them with an open mind, kindness and a large helping of self-compassion they may just help you and your team make better decisions, take control of your workload, and start to enjoy what you do again.

Our Resilient Team Academy online membership for leaders in health and social care provides conversations canvasses, coaching demos, video training modules, bite size team building videos and deep dive live webinars to help leaders and managers have these important conversations and support their teams care for resilience, wellbeing and productivity. Doors to the RTA are open right now and we have discounted packages for Ockham Healthcare subscribers, and packages for PCNs and other organisations. Find out more here or get in contact with Ben (ben@ockham.healthcare).

You may also be interested in watching a recording of a recent webinar that Ben and I did, ‘How to support your team through the new ways of working in primary care, without burning out yourself.’ You can find it here.

20
oct
0

A Reminder of the Value of Independent Contractor Status

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Last week NHS England published, “Our Plan for Improving Access for Patients and Supporting General Practice”.  It is a document that lacks coherence, and is clearly a performance management document that has then been added to to try and make it ‘acceptable’ to the profession (e.g. add “and supporting general practice” to the title).  This hasn’t worked, and, understandably, it has created an angry reaction across the general practice.

In the NHS direct performance management like this has been common for a number of years.  Statutory NHS bodies such as Acute trusts, Community Trusts, CCGs (etc) receive edicts like this that demand certain actions and delivery on a reasonable regular basis.  These are then reinforced by senior leaders not achieving the targets being summoned to local then regional then even national performance meetings.  There was a time in the not too distant past when acute trust chief executives not meeting the 4 hour A&E target were being summoned to meetings with the then Secretary of State Jeremy Hunt.

This style of performance management is a particularly unpleasant side of the NHS.  It comes because those in the highest positions of the NHS have to demonstrate they have levers they can pull to make things happen on the ground, when they themselves are under pressure.  We have a new Secretary of State and a new NHS Chief Executive, and the bigger worry is that this is just the first taste of what life is going to be like under this new regime.

But if nothing else, the document is a timely reminder of the benefit of the independent contractor status that general practice enjoys.  The reality is that the Secretary of State cannot directly tell GPs what to do, or instruct how they should behave, in the same way that he can with NHS Chief Executives and senior leaders.

Whilst the document might feel like direct performance management (it is designed to), it is in fact an instruction for how NHS staff that are under the direct control of NHS England are to manage the contract they have with general practice.  They are the ones who are to submit returns by the 28th October, not practices themselves.  For general practice, its responsibility lies in making sure it delivers against the contract it has signed up to, nothing more.

For those who have not read the document (and it is not a read I would recommend), it essentially outlines a series of measures that it will introduce to try and increase the number of face to face appointments GPs hold with their patients.  They will use the data practices are now submitting to publish waiting times at practice level, and send a ‘hit squad’ into the practices with the longest waits.  The NHS is asked to compile a list of practices where the number of appointments is lower than pre-pandemic levels, of the 20% of local practices with lowest level of face to face appointments and with the most significant level of 111 calls in hours and A&E attendances compared to expected, and of where concerns have been raised with CQC and others.

The NHS is then to use this data to create an overall list (by 28th Oct) of local practices where “it will be taking immediate further steps to support improved access” (43).  These actions are to include “partnering with other practices, federations or PCNs”, and “contract sanctions and enforcement” (45).

Pretty grim stuff.  It is effectively an instruction for commissioners to use any contractual lever they can to make practices see more patients face to face.  They themselves will be directly performance managed on this, as they are “required to produce a fortnightly updated report for their region” (48).

For GP practices the best thing to do is simply ignore it.  As long as you are happy with the balance of remote to face to face appointments in your own practice and are confident you are meeting your contractual requirements, then don’t do anything.  The worst thing that could happen would be for this approach to be effective, because it would encourage the new national NHS leadership regime to do more of the same in future.  Practices have enough on their plate to content with right now, so let commissioners manage the flak that comes from above.  The good ones do this regularly and they do it well.

If general practice was part of the NHS (as opposed to an independent contractor) it would be having to manage this itself.   Independent contractor status is hugely valuable, and one general practice would do well to hold on to as long as it can.

13
oct
0

What do ICSs and PCNs mean for GP Practices?

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There is so much going on in general practice right now, and the workload pressure is so great, that it is easy to take a head down approach to everything that is going on outside the practice.  But the landscape around practices is shifting.  What do these changes mean for individual practices?

The big change is the introduction of Integrated Care Systems (ICSs).  This change is one that most practices are largely ignoring, but one that has significant implications for practices.

One of the reasons there is little interest shown by practices is because it is a change that is rarely clearly explained.  At its most simple the way the NHS is being organised will no longer be through a separation between purchasers (or commissioners) and providers.  Instead providers will directly work together to agree how care should be delivered, what the pathways should look like, and how the money should be spent.

In practical terms, CCGs will cease to exist from March next year, and they will be replaced by new NHS ICS bodies.  These role of these organisations is essentially to enable the joint working between providers that lies at the heart of the new system.  As a result all provider organisations are represented on the Boards of the new NHS ICS bodies.

ICSs will function on two levels.  There will be the whole-ICS level, where broader strategy decisions will be taken, but then also at local levels within the ICS area.  This local level is what is being referred to as the ‘place-based’ arrangements.  This will generally be the local area or borough that general practice has been part of for many years.

In most ICSs much of the decision making, including resource allocation, will be devolved to these local areas.  This will include funding for any local enhanced services/local incentive schemes for general practice.

At the heart of integrating care within a local area lies Primary Care Networks.  These were created not in splendid isolation from the rest of the system, but with the emerging ICS explicitly in mind.  The role of PCNs within the new system is to create seamless care for physical and mental health across primary and community care, to enable care to be delivered as close to home as possible, to create seamless pathways across primary and secondary care, to strengthen the focus on prevention and anticipatory care, and to support people to care for themselves.  The PCN is the core building block of the new integrated care system.

All of the work that PCNs have been asked to do so far (primarily via the PCN DES) has been with this in mind.  It underpins the specifications that have been developed within the PCN DES, and the indicators within the Investment and Impact Fund (IIF).

The asks and requirements so far on PCNs are only the beginning.  They will inevitably grow, and increasingly these will come from the local place-based Board of the new ICS (i.e. the one that sits at a local level), as opposed to nationally via the PCN DES.

When PCNs were announced as part of a 5 year contract for general practice in 2019 the funding split was as follows: £1bn extra to come via the core contract, £1.8bn to come into general practice via PCNs.  The more recent uplift in ARRS funds to cover 100% of salaries from 70% means the split in reality is more like £1bn to £2bn.  Most new general practice funding is already coming via PCNs.

But PCNs are only just getting started.  The ICSs do not become statutory bodies until April next year, when we will already be 3 years into the 5 year GP contract, with only 2 years remaining.  What will happen then?  Most (if not all) of the local enhanced service contracts from the ICS place-based board will come at a PCN not practice level.  The differential in funding growth after 2024 if anything is likely to be greater than from this 5 year agreement (i.e. the vast majority of resources coming into general practices will be via PCNs rather than via the core contract), because the foundation the whole new system is being built on is PCNs.

All of this means there are two really important things practices need to be doing now.  The first is to start treating the funding and resources the practice receives via the PCN as part of its core resource, and not as an optional extra separate from the ‘real’ business of the practice.  Investment into general practice is coming via PCNs, and so practices that try and sustain themselves into the medium term on core contract income alone are going to find life extremely difficult.  This may in turn have consequences for how practices choose to interact with their own PCN (a topic I will return to in a future blog).

The second is that practices must ensure that their PCN is directly engaged in the Board and leadership arrangements of the local-place based Board of the ICS.  I know the level of meeting requests in relation to the system and ICSs is bewildering at present, and can feel like a waste of time, but the one ICS meeting that PCNs must prioritise is this local place-based Board.  Each PCN has a seat on this Board to represent local general practice, and because this Board will have such a strong influence on how care is organised locally, and how resources are apportioned, it is critical PCNs take up this seat and do not leave it empty.

6
oct
0

A 3 point ICS Strategy for Local General Practice

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What is the plan for general practice within an Integrated Care System (ICS)?  It seems that for most the pressure of everyday life is far too much for GPs to be even thinking about this question, let along working out what the answer is.  But if general practice is to have a voice in the new system that is developing some form of plan is necessary.

For local general practice to have as big a voice as possible, and in the absence of any more tailored local solution, I would suggest the following as simple 3-point plan.

  1. Push for as much as possible to be devolved to place-based arrangements

ICSs are to work on two levels.  There is the overall ICS level, and a  number of local ‘place-based’ levels.  Each ICS has to decide how the local place based arrangements will work.  Specifically it has to decide whether to use the local arrangements as advisory within the wider ICS decision making, or whether to devolve decision-making authority to the local level.

The reality is that the influence of general practice will be much greater at a local level than at an ICS level.  An ICS Board only has to have one GP.  That GP will be appointed and in no way has to be representative of general practice.  However, at a local level the PCN Clinical Directors (CDs) are to represent general practice on the local place-based board.

It is difficult for general practice to establish consistent and shared views across practices.  The bigger the area, the harder the challenge of creating a shared view across practices is.  It makes sense to try and push decision making down to a local level, to give general practice the best chance of creating a consistent voice.

On the plus side the local councils will also be pushing for decision making to be devolved to a local level.  While there may be challenges ahead with the council within the place-based board now is a good time to ally with them to influence the ICS to establish a devolved decision making model.

  1. Create an Integrated Voice for General Practice at a Local Level

The challenge for general practice is to bring together all the constituent parts of general practice together to create a single, unified and therefore powerful voice.  This includes the individual practices, the PCNs, the local federation and the LMC.  For general practice to have influence with other system partners it needs to speak with one voice.  If it spends its time contradicting itself (e.g. the LMC speaking against the PCNs) then its voice can simply be ignored by system partners.

The areas that have had most success have done this at a borough or local level.  I wrote recently about what we can learn from the experiences these places have had.  Some ICSs are trying to push practices into creating a shared voice (or general practice ‘collaborative’) at ICS level.  It is hard enough making this work at a local level, and my strong view is that if you attempt to do this at too wide a level the internal arguments will be too difficult to overcome and the net result will be an extremely weak voice for general practice.  Far better to create local arrangements, and then ask the leaders of these local arrangements to come together and influence at an ICS level.

  1. Make Use of the Opportunity to Influence at Local Level

This strategy only works if once the ICS has agreed to devolve decision making to a local level that general practice actually takes the opportunity to influence decision making locally.  It means PCNs and practices working together to identify their priorities and to push these in the local meetings.  It means building relationships with local leaders and taking an active role in the working of the local place-based partnership meetings.

This is more challenging than it sounds.  PCN CDs are overwhelmed as it is with meetings and demands on their time.  The delivery responsibilities for PCNs have just been ramped up.  It is easy to ignore the local ICS partnership board as one more meeting that you don’t have time for.  But losing control of this now and giving it up to local authority and community providers who will be eager to take it would be a mistake that general practice could rue for a long time.

Not only does local general practice need to come together and create a single voice.  It needs to establish how it will discharge this voice and influence the local meetings.  This involves identifying one or two senior leaders who it will choose to build relationships with the other local leaders to represent general practice in discussions and at these meetings.

This three point strategy will only work if all elements are carried out.  If decision making is devolved but local general practice cannot agree with itself, its voice will still be weak or limited.  If it doesn’t attend the meetings or find a way of ensuring its views are adequately represented the same will apply.  However, if done well the rewards could be significant, as it is an opportunity for general practice to work with other providers and shape the provision of healthcare in their area.

29
sep
0

Why Extended Access is so Controversial

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There is a storm brewing in general practice.  Not unusually it relates to access, and more specifically extended access.  The ramifications are significant for PCNs more widely and the ability of general practice to be effective within local Integrated Care Systems.

What exactly then is the problem?

Right from the inception of PCNs it was announced that the funding for extended access would shift from the CCGs to the PCNs.  Originally this was planned for a year ago, but then this was delayed for unspecified covid-related reasons to April 2022.  It does look like it will happen this time round, especially because CCGs themselves will no longer exist at that point.

The current situation is that either local practices via a federation or an external provider deliver extended access.  This is not the same as out of hours, but covers 6.30–8pm on week days and 8am to 8pm at weekends.  Out of hours providers cover the 8pm to 8am period.

The issues can be broadly broken down as follows:

  • Where an external provider delivers the service there is often unhappiness with the quality of service provided, and many local GPs have a sense that a better service could be put in place, particularly given the amount of money on offer.

 

  • Extended access is funded at £6 per head of population. Given the requirements placed on the service, this feels generous to many GPs when compared to the core funding they receive.  We do not know whether this will be the funding level transferred to PCNs, or whether the service requirements will remain the same, but some practices believe it would make financial sense for extended access to be directly delivered by the practices in their PCN.

 

  • Many practices are at breaking point already. Regardless of the finances, there are many practices who are vehemently opposed to taking on extended access at a practice level.  The issue for these practices is that their staff cannot cope with the workload they have, and to then ask them to cover extended hours is untenable.  Those with longer memories view it as a step back to the pre-2004 days when GP practices were responsible for their own out of hours cover, and are passionately opposed to any such movement.

 

  • Federations use extended access funding to carry out far more than extended access. The relatively generous funding to date for extended access means that many GP federations have been able to build an infrastructure to support the delivery of at-scale general practice based on the extended access contract.  This has often included support for PCNs, delivery of vaccination services, delivery of resilience programmes (etc).  If the extended access contract is moved away from the federation by the PCNs then the whole at scale delivery capability for general practice that sits within the federation is put at risk.

The issue is hugely divisive because there are those practices who are adamant in their refusal to take it on, and practices and PCNs who are very keen.  Areas without a federation are already starting to feel forced into having to deliver this service, whereas areas with a federation are having to weigh up the impact on the federation as well as the impact on the PCN and its practices of any decisions they make.

The whole issue is unsurprisingly leading to increasing tension and animosity within general practice, just when it needs to be creating a united front.  The ongoing delays in the guidance from NHS England (it was due last year, then this summer, now it is due this autumn) are exacerbating the situation because without clarity on the requirements and the funding no one is in a position to make a final decision.

It is a controversial issue that is likely to become more divisive in the short term.  It falls to local general practice leaders to help navigate a way through this that works best for local practices and their populations, and not allow it become something that prevents general practice working together and having the united voice it so urgently needs within the emerging Integrated Care Systems.

22
sep
0

Making General Practice Effective within an ICS

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A key challenge for general practice operating within an Integrated Care System is how it establishes a single voice, and how it exerts influence given the strength and size of system partners such as acute trusts and local councils.  But already up and down the country we are starting to see local areas work through exactly how they will do this.

Establishing a unified voice is difficult for general practice. The independent contractor model, and 7000+ units of general practice, puts it at a distinct disadvantage compared to local providers.  Often there will be one acute trust, one council, one community and mental health provider and then anything between 5 and 10 PCNs and 40-50 individuals practices in any local ‘place-based’ area.  Across the ICS as a whole it is even worse, as there can be literally hundreds of practices, dozens of PCNs, but one (often merged) acute provider and one or maybe two community and mental health providers.

In this set up it is not hard to see how the unified voice of these single providers, with their hierarchical structures and large management teams, is going to be more powerful than that of general practice, given its relatively disparate nature and lack of any form of comparable management support.

But what we are now seeing in different parts of the country are attempts to bring the different parts of local general practice together to create some form of a unified voice.  There is superb example of this in Herefordshire, which we featured recently in an episode of the podcast.  There they have established what they term a ‘General Practice Leadership Team’, which comprises the federation leads, the PCN Clinical Directors, the LMC, and even the CCG Director of Primary Care.

This leadership team works through things together and agrees a single voice on issues, as well as providing a forum for general practice to meet with system partners where it is needed.

Other areas are equally bringing together the federation directors and the PCN CDs and the LMC into an overarching local leadership group for general practice.  Sometimes this is done within a federation infrastructure, and sometimes it is created separately to the local federation but with federation input.  Of course sometimes there is no federation, but I am yet to find an area without one who has actually started on this journey (do get in touch if you have!).

What early lessons can we learn from those areas who are taking the early steps along this journey?

The first is that there is no right way of doing it.  All of these systems rely on trust.  So the important thing is whether all those round the table are bought into the need to create a single voice for general practice, and whether the people leading the group are trusted.  Interestingly in Herefordshire the group is chaired by a manager, the Director of Strategy at the federation, but that works because she has the trust of those round the table, has good system relationships in place, and can take a neutral stance, i.e. is not seen as favouring their own practice/PCN over others.  More commonly there is a trusted GP at the helm.  What is clear is that it is trust in the person leading that is important, rather than their role or background.

The second is that system influence is a function of relationships, not just attendance at meetings.  What that means is that those leading need to be given the time to build relationships with the other system leaders.  While there is a benefit in distributed leadership (i.e. different individuals taking on different aspects of the system leadership requirements), there is also the need for a focal point and someone who is enabled to invest the time to build relationships with the individual local leaders of the other organisations.

The third is to be effective this type of system requires clarity on the roles of all concerned.  It is not an abdication of autonomy of the general practice organisations around the table to the group.  It is a place where decisions can be made about what requires a group decision, and what remains the responsibility of the PCN or federation or LMC (etc).  It requires clarity about if someone is purporting to speak in the name of the whole of local general practice exactly what process is in place for them to be able to do that, i.e. how is that individual engaging or briefed beforehand, what can they agree/not agree, and how do they feedback and implement any actions picked up.  And it requires clarity as to where delivery responsibility lies, as the group only provides a coordinating function (it is very rarely an entity in its own right).

The fourth is that such a system or infrastructure will take time to develop and become effective.  Trust (the key ingredient) has to build along the way.  And given how close we are to these new systems going live it is probably a journey that every area needs to be thinking through now as to how this is going to work locally.

This could be left in the ‘too difficult’ box (because of the size of the challenge!) but that then leaves general practice hugely exposed in the new system, with little hope of exerting effective influence on local decision making and resource allocation.  If there is no movement in this direction locally I would suggest the best starting place would be a conversation between the PCN CDs and the LMC to agree how to get started.

15
sep
0

Dos and Don’ts for the Next Phase of PCNs

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The recent PCN guidance signalled a new phase for Primary Care Networks.  In a recent blog I examined the guidance in some details.  The upshot, though, is that delivery expectations on PCNs will increase significantly from the start of October, and then again from March next year.

Covid has directly impacted on PCNs over the last 18 months.  Amongst other it postponed some of the delivery expectations to allow practices to deal with the pandemic and to roll out the vaccination programme.  Meanwhile the ARRS investment has continued.  Now the transition from set up to delivery is happening very quickly, instead of the more gradual shift originally intended.

This is significant for PCNs.  It means a move away from considering how to best use the ARRS funds to requiring a much stronger focus on delivery against the DES specifications, the IIF indicators, and any local schemes that may be in place.

So the set up phase of PCNs is effectively coming to a rather abrupt end, and we are entering a new delivery phase.  How should PCNs respond to this change?  Here are my top 3 ‘Dos and Don’ts’ for PCNs in making this transition.

DO

  1. Do be explicit about the link between PCN and Practice Work

Since 2019 the uplift in funding to the GP contract has come almost exclusively through PCNs.  This trend will continue for the next three years until 2024, and is highly likely to continue beyond that.  The funding and resources that will come to practices via PCNs will soon make up a key part of a practice’s income.  Participating in PCN delivery is not separate (and additional) to a practice’s core work; it is part of it.  For practices in a PCN to make the most of the PCN opportunity they need to work together, and make sure a commitment is in place from each practice to meet the delivery requirements.

  1. Do firm up the agreement between practices in relation to delivery

It is crunch time.  Some PCN targets can only be achieved if each practice plays its part.  But what happens if one practice does not meet the delivery requirements?  What if that means the whole PCN loses out financially? What are the consequences?  How will the PCN respond?  Will the practice have to recompense the other practices for any income lost? How will it work? It is really important practices within a PCN have a clear upfront agreement in place of exactly what the requirements in relation to delivery are, and what will happen if these are not met.  Without these in place life could become extremely difficult over the next few months.

  1. Do put management support in place

Many PCNs have some management support in place, but some still do not.  The latest guidance promises £43M for ‘PCN leadership and support’ this year.  If it is not already, ensuring delivery against all of the new requirements will be impossible for PCN CDs to do on their own from October, so use this funding to put some management support in place.

DON’T

  1. Don’t Change PCNs

Being in a PCN can cause relationships to fray, and working together can sometimes feel more difficult rather than easier over time.  But if you have got this far with your PCN configuration don’t be tempted to change it now.  Changing PCNs means doing all the start up work all over again, and frankly there is not the time to do this as well as meet all the delivery requirements.

  1. Don’t ignore the fact that a practice is not delivering

Conflict is difficult, and PCNs have been working hard to build relationships between its practices over the last two years.  But if a practice is not meeting its extended hours commitments or its care home requirements, and that is impacting the PCN as a whole, then it needs to be tackled.  Ignoring non-delivery now sends a message that non-delivery is ok to everyone, which in turn will make effective delivery across the increasing range of requirements almost impossible to achieve.

  1. Don’t waste your time in pointless meetings

The value of PCNs will ultimately come from their ability to make a difference to their local population.  It will not be determined by the number of system meetings that the PCN attends.  This phase for PCNs requires an internal focus to make sure they are each able to deliver effectively.  A PCN’s influence will increase if it can gain a reputation as one that can make change happen, versus one that attends a lot of meetings with little end product.

8
sep
0

What Next for General Practice Nursing?

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General Practice nursing has reached something of a hiatus: the ten point action plan published in 2017 has expired and as it stands there appears to be nothing new taking its place.  At the same time the Primary Care Networks (PCNs) dominating much of the general practice agenda make relatively little mention of the nursing workforce.  So where does this all leave general practice nursing?

At the time of the publication of the General Practice Forward View in 2016, along with the subsequent 10 point action plan for general practice nursing, there was a gentle optimism that the problems within the general practice nursing profession were finally being recognised, and action was being taken to resolve these.  But fast forward to five years later and it seems the situation remains critical.

While the numbers of nurses attracted into general practice has risen over the last few years (NHS Digital data reports just over 24,000 nurses in 2020 compared to c15,000 in 2015), the fundamental problems in relation to retention of these nurses remain.  The aging workforce, the lack of career opportunities, and the generally poor support for nurses all contribute to the retention challenge.  General practice nurses are funded via the core general practice contract, have no direct influence on the contract negotiations and are not part of agenda for change, and the inequity of pay this generates is the source of much frustration.

PCNs have not helped.  Many nurses are angered by the lack of mention of general practice nursing in the PCN documentation, in particular in relation to the additional roles coming in via the PCNs.  It makes already undervalued nurses feel even more underappreciated, while other professions brand new to the sector receive all the support and attention.

Nurses have provided the frontline of face to face care in many practices during the pandemic.  While many clinical staff were able to function through the use of remote consultations, it was often nurses who had to continue the face to face work such as immunisations and vaccinations, right at the time when the situation was at its worst.  The Queen’s Nursing Institute’s General Practice Nursing Report published last year includes many individual examples of this, and there is no doubt that many GPNs felt exposed to increased risk compared to other workers.

Where does all of this leave the profession now?   Ironically, the introduction of the other roles, and the challenges associated with this, has reinforced for many GPs the value of GPNs.  It is a source of frustration for GPs as much as the nurses that they cannot use the ARRS funding to strengthen this particular workforce.  Despite this, there should still be a place within PCNs for practices to consider how they are supporting their nurses alongside the other roles.

The nurses themselves also have a role to play.  Mel Lamb, a recent podcast guest, describes the need for a change in mindset from the nurses themselves to be more proactive about the opportunities that do exist, and to take more of a leadership voice in how general practice operates.  We have seen the emergence of the Institute of General Practice Management in the last year creating a national leadership voice for practice managers, and it does seem that a similar kind of unifying impetus is needed for GPNs.

National support and action is also required.  It is impossible to look at where we are now, review the progress made over the last five years and decide the job is done.  It cannot be left to the discretion of local areas to determine whether any more action is taken.  There has been some great work started via training hubs, federations and other organisations and these need to continue to be supported and funded, alongside a proper focus on how this critical staff group can be retained, to ensure any gains made are not lost in the next five years.

1
sep
0

What to Make of the New PCN Guidance

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NHS England has recently published new guidance for PCNs, which covers the requirements for PCNs in relation to the DES specifications and how the Investment and Impact Fund will work for the 18 months from October.  This week I explore the implications of this guidance for PCNs.

Additional funding for PCN leadership and management support (£43m this year) is announced.  While PCN Clinical Directors certainly need more management support to help them with the role, this funding has to be taken with two important caveats.  First, there is no indication as to whether this funding is recurrent or not, and second there does not appear to be any extension of the additional Clinical Director funding itself (which had been increased for the first 9 months of this year).  So rather than “additional funding” it could probably be more accurately described as a re-badging (and reduction) of funding that PCNs are already currently receiving.

What is certainly good news is the announcement that PCNs will not be expected to deliver all of the additional PCN DES service specifications from 1st October, as had previously been signalled.  PCNs have to start with two: CVD prevention and diagnosis and tackling neighbourhood health inequalities.  Even these have been given an 18 month implementation timetable, meaning that the requirements for the first six months are not the full specifications.

Alongside this, the guidance announces the requirements for the anticipatory care and personalised care service specifications for 22/23, meaning PCNs are able to prepare for these now.

Of course the question all along has been where the funding for the additional work in each of these specifications is coming from.  What has become clearer with this publication is that the Investment and Impact Framework (IIF) is intended to provide direct funding support (or ‘incentives’ as NHS England like to term it) for the specifications.  Previously just over £50M had been allocated for the indicators in the IIF from April, but now new indicators have been added from 1 October that take the total national investment to the previously promised £150M.

As an aside, I find talking in these national, aggregated figures extremely unhelpful.  I understand it works for politicians and national figures when they are trying to demonstrate they are investing in general practice, but what a PCN needs to understand is exactly what it means for them (or even for an ‘average PCN’).  The original (£50M) IIF funds meant just over £40,000 was available to the average PCN, and this effectively triples that now this year to just over £120,000 for the average PCN.  In 2022/23 the total available increases to £225M, or £180,000 per PCN.

In the revised IIF there are a total of 666 points now available in 21/22 across 19 indicators.  This jump from just 6 indicators at present will need managing by PCNs.  80 of these points are allocated to the CHD specification (i.e. around £14,500 per PCN) and 56 to the health inequalities one in 21/22 (around £10,000 per PCN).  This does stand in contrast to the 222 points allocated to improving access to primary care services (or 166 if you don’t want to double count the health inequalities indicator, although even that indicator is not about tackling health inequalities per se, but rather health inequalities specifically in relation to access to GP services).

This latest guidance highlights that the focus on access to general practice is firmly back on the agenda.  I am not sure it ever really went away, but PCNs took primacy over access in national policy making for a couple of years, but we are certainly seeing it make a comeback now.  NHS England have produced this chart that summarises ‘PCN objectives’ for the next 18 months, and out of nowhere ‘improving patient access’ has appeared as one of the top 5 objectives for PCNs.  At the same time, supporting and sustaining core general practice is notable by its absence from this list.

Guidance had been promised on the transition of commissioning extended access services from CCGs to PCNs in the “summer” of 2021.  This letter states that this will now be available in “autumn”, but the deadline for the transition remains as April 2022.  This guidance was due last year, and has now been put back again, so it is clearly proving difficult to agree.  NHS England is probably stuck between a rock and a hard place with the government demanding more and more in relation to access, and the GPC unwilling to agree that PCNs will deliver more for less.  In the meantime PCNs are expected to have “undertaken good engagement with existing providers”, which in the absence of any guidance or indication of funding levels is something of a nonsense.

So that’s it.  There was always going to be a scaling up of expectations on PCNs, and we are starting to see this now.  It will soon be impossible for PCN CDs to manage PCNs on their own, simply because of the scale of the demands and delivery responsibilities upon each PCN.  For PCNs to work they need to do more than just what NHS England wants them to, as they also need to make a difference to their own member practices.  This latest guidance reinforces the need for PCNs to make sure they have they have clearly set their own priorities (so as not to be simply swamped by the national ones) and have the infrastructure in place to meet the ever-expanding requirements placed upon them.

25
aug
0

Is General Practice Making the Most of CCG Clinical Directors?

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Over the last 8 years a wealth of skills, knowledge and experience has built up within a relatively small group of GP leaders who took on Clinical Director roles within Clinical Commissioning Groups (CCGs).  Now that CCGs are coming to an end, what will happen to these Clinical Directors?

The first thing to say is that some CCG Clinical Directors have taken matters into their own hands and have taken on roles as PCN Clinical Directors, thus cementing their place in the new system.  But there are still a considerable number continuing to undertake their CCG roles whose places are less clear moving forward.

The context this sits in is the shift of the system as a whole from a commissioner provider split to one of integrated care systems (ICSs).  Within ICSs the different providers are expected to collaborate and work together to decide how care will be delivered and how resources will be deployed.  One of those providers is general practice.

Many of the functions of CCGs are transferring directly over to the new NHS ICS bodies.  It may well be that roles have or can be identified within these bodies for the GPs in CCG Clinical Director roles.  But the key question is whether general practice as a whole wants these GPs to be deployed providing clinical advice and leadership across the system within the ‘neutral’ NHS ICS bodies, or to be more squarely deployed as part of the leadership team of general practice?

Within CCGs GP Clinical Directors have an explicit remit as GP leaders within GP membership organisations responsible for the health of the whole population.  Within an NHS ICS body, it is less clear that any clinical leadership role should be filled by a GP.  They could just as legitimately be filled by clinicians from anywhere across the provider landscape.

If general practice is to genuinely operate as an equal partner with an equal voice within ICS discussions, it will need leaders who are able to develop strategy, think strategically, and operate politically.  These are exactly the skills that CCG CDs have been developing over the last 8 years, and are not skills that commonly exist amongst the provider-based GP clinical leadership teams.

The Consultant leadership within an acute trust is primarily deployed in medical and clinical director roles within the hospital.  It is only when these roles are filled that it will start to consider supporting system roles.  General practice is in danger of having this the other way round: making sure the system roles are filled before ensuring it has the internal leadership skills and expertise it needs.

History is, inevitably, getting in the way.  GPs who have undertaken CCG Clinical Director roles are sometimes perceived as being distant from core general practice, particularly when they may have been on the commissioner side of developing services and specifications that practices may not have been happy with.

Equally funding is a barrier.  CCG Clinical Directors were well remunerated for their time, and there is no obvious source of remuneration for GP leaders outside of the PCN Clinical Directors at present.

But general practice in every area needs to think through how it is going to be effective in the new world of ICSs.  CCG CDs are a hugely valuable resource for general practice, and the service as a whole would be well advised to consider how it can ensure that this resource is deployed where general practice needs it, rather than passively allowing the system to decide where it should go.

18
aug
1

How Does the System View General Practice?

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When you are working day in and day out in general practice, it is easy to lose any sense of perspective as to how the profession is viewed by those elsewhere in the system.  What do others think of general practice, and whatever it is, does it matter?

The reality of the purchaser provider split has meant that the views of others has not really been an issue for a long time.  Whether the local hospital or council ‘rate’ general practice has been neither here nor there, as the contract is primarily negotiated nationally, and locally there has always been a strong GP presence within the local commissioners.  This of course was baked into the design of Clinical Commissioning Groups, and was a staple of its predecessors Primary Care Trusts and Primary Care Groups.

Now things are about to be different.  The premise of Integrated Care Systems (ICSs) is that they are a collaboration between providers, who will agree between them how to design services and deploy resources.  The requirement for ICSs as legal entities to have GPs within their design is limited to say the least – one GP on an NHS ICS Board (not as a representative of the profession), and PCN involvement in place based arrangements (more explicitly to represent primary care).

The national GP contract will remain.  However, increasingly we are seeing any additional resources deployed through PCNs rather than direct to practices.  This trend will continue until 2024, and most likely beyond that.   This means (amongst many other things) the deployment of local resources to general practice will be essential, via enhanced services and the like.  The extent to which this happens, however, will be down to the local ICS.

The local ICS will be comprised of the various system partners.  The acute trust, the community trust, the mental health trust and the local council will be extremely powerful voices within the new arrangements.  So it will matter, for the first time in many years, how general practice is viewed by these partners.

How do those across the system view general practice?  Do they view it as a trusted partner, as a service that is worthy of investment, as the front line in the delivery of health and care?  Will the primary motive of each ICS be to invest as much resource as possible into general practice to improve the functioning of the system as a whole?

Of course views will vary across the country, and there will be a range of perspectives that are held.  The views will locally be influenced by personalities and the strength of relationships that exist at senior levels with local systems.  In some places GPs have rubbed local political leaders up the wrong way over a number of years, whereas in others extremely strong relationships have developed.  The credibility of the senior GP leadership inevitably affects the credibility of the service as a whole.

The underlying concerns that system leaders in some areas hold about general practice, whether they are valid or not, is the extent to which investment in general practice leads to any real returns.  There are concerns as to whether general practice is pulling its weight when it comes to the pressures on the urgent care system, with many (particularly in acute trusts) viewing the stories about lack of availability of GP appointments as a direct cause of downstream system pressures.  Council leaders on the other hand often bemoan the lack of impact the recent investment into general practice has had on health inequalities, and can sometimes hold the perception that practices are more motivated by money than by making a difference to the populations that they serve.

All of this can lead to an overriding sense from some system partners that general practice collectively is dysfunctional and fragmented, and that the consequences of this are felt by other parts of the system.

Don’t shoot the messenger!  In your area everyone may hold general practice in particularly high esteem.  There is no question that many have been impressed by the role general practice has played in the roll out of the vaccination programme.  But it may still be worth checking.  How others view general practice is more important now than it has been for at least 20 years, and where there are negative and unfounded perceptions in place it is critical that general practice takes action to start to correct these.  If it does not, life in the new system could start to prove very difficult indeed.

11
aug
0

What is the Role of LMCs in Integrated Care Systems?

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As we move into the new system of Integrated Care a question is emerging around the role of LMCs, and how it will be impacted by the change.

In a traditional purchaser provider model it makes lots of sense to have someone whose job it is to negotiate contracts on behalf of the provider.  Hospital trusts have contracting teams, and general practice has the GPC nationally and LMCs locally.  LMCs have a statutory duty to represent GPs at a local level, and are mandated to represent and negotiate on behalf of their local GP practices.

Whilst recognised by statute and having statutory functions, LMCs are not themselves statutory bodies.  They are independent, and it is this independence that means most GPs and practices trust their LMC to stand up for and support them.  Current legislation includes a requirement for NHS Bodies to consult with the LMC on issues that relate to general practice in their locality.

However, the new guidance on Integrated Care Systems states,

“It should be recognised that there is no single voice for primary care in the health and care system, and so ICSs should explore different and flexible ways for seeking primary care professional involvement in decision-making.” p27

It then goes on to say,

“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. This work is in addition to their core function and will need to be resourced by the place-based partnership.” p28

LMCs are not explicitly mentioned in the guidance.  The implication of the paragraphs above is that it will be PCNs representing primary care (i.e. not LMCs), and it will be up to each local area to decide how LMCs should be involved.

The challenge is that fundamental to integrated care is the need for collaboration and joint working between partners.  This requires give and take on all sides, something LMCs will find difficult because their mandate is only for general practice, and it would be hard for them to justify making concessions around the role of general practice for the greater good to their member practices.  The reality is most LMCs would not, and it is for that reason that those establishing place based arrangements in most areas will be reluctant to include LMC representation.

But if the LMC are not included it potentially serves to make life difficult for those who are representing general practice within the integrated care arrangements.  It is going to be hugely undermining if the representative agrees something for general practice, only for it to be rejected by the LMC (and then most likely member practices) at a later stage.  It won’t just be undermining for the individual leader, it will actually serve to undermine the voice and influence of general practice within the system, as it will reinforce the lack of confidence that some parts of integrated care systems have in general practice.

Any system that is formed as a collaboration of different organisations will necessarily be political.  Integrated Care Systems will be no different.  If general practice is going to be effective within the new systems it will need to find ways of bringing LMCs and PCNs (plus federations and any other general practice leaders) together itself, so that it can operate collectively and effectively.  The system is not going to do it for general practice, and unless general practice can create its own internal coherence it is at risk of having little or no influence on the new system as it develops.

4
aug
1

What is the Right Size for a PCN?

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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.

28
jul
0

Can General Practice Lead an ICS?

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As the NHS shifts away from the purchaser provider split and into the new world of integrated care, can general practice actively drive the agenda? Or is the ability for general practice to be proactive locally made impossible by the national contract?

At its heart integrated care is built upon the notion of the different providers of health and social care working together to improve outcomes for patients.  Instead of competing with each other, the providers seek to actively collaborate in order to make the best use of the resources available.

If we take even the place-based arrangements, the ones within an ICS where general practice is guaranteed a seat at the table via PCNs, then there will be representatives from acute, community, mental health, social care, the voluntary sector alongside general practice.

The first and most obvious question is whether general practice can provide a unified voice within this arena.  I discussed this in more detail recently, and the need for PCNs to find ways of establishing a single voice.  But this is not the only challenge.

The potentially greater challenge is whether general practice can be proactive in the discussions, or even lead them.  Can general practice come to the ICS table and drive the agenda?  Can the strategic direction be set by general practice, so that meeting the needs of the population that general practice often understands best is prioritised?  Or will the discussions be driven by the large providers such as the acute trusts, demanding to know how primary care is going to support a reduction in attendances at A&E, or help tackle the backlog of outpatient attendances?

The problem is that in recent times general practice has become mostly reactive.  The way that general practice operates is by being offered things e.g. changes to the national contract, national Enhanced Services like the PCN DES, or local enhanced services, and then responding to these offers.  It reacts to the proposals that are put in front of it.

Alongside this reactivity there is very commonly a learned local helplessness.  Most practices feel too small to be listened to, that their voice is not heard, and that no one understands the pressure they are under or what life is really like in general practice.  They do not feel able to influence the system, only able to react to the demands or requests that are made of them.

To some extent this is due to the national GP contract.  Any one of the 7,000+ individual GP practices is too distant from the negotiation of that contract to really feel able to influence it.  As it forms the largest part of general practice income the national contract provides security, but the price of this is a sense of local powerlessness.

None of this helps general practice if it wants to be influential and proactive within local ICSs.  For local general practice to be influential it needs to not only have a collective voice, but be able to proactively flex its offering into the local system.  “Collective voice” has to mean more than an ability to react collectively, it has to mean operate effectively together to come up with and drive changes across itself as well as the rest of the system.

How realistic is this?  There will undoubtedly be those who are at the head of the curve who are proactively thinking this through and working out a way to do it.  But for the majority at present this seems out of reach, and without strong local leadership it seems unlikely general practice will be able to play a role proactively shaping the direction of local ICSs.

21
jul
0

What will happen to Primary Care Commissioning?

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As we move into the new world of Integrated Care Systems (ICSs) and come to the end of the purchaser provider split, what should happen to the primary care teams that currently sit in CCGs?  Will we make the same mistakes as 8 years ago when CCGs were formed, or will a more forward thinking approach be taken?

For those who were not around back in 2013 when CCGs were first formed it was Primary Care Trusts (PCTs) that were being abolished.  The primary care commissioning function sat within PCTs, and was moved to NHS England, because of the dreaded ‘conflict of interest’ concerns that surrounded the idea of GP-run CCGs commissioning from themselves.

What followed was an inability of the regional NHS England teams to meaningfully engage with practices, because the distance was too great alongside a huge loss of skills and expertise.  In the end, it was decided that the conflict of interest wasn’t that great after all and the commissioning of primary care was ‘delegated’ back to CCGs.

What we learnt from that sorry episode was even though general practice is essentially commissioned through a national contract, practices do need local contractual support, local problems need to be discussed and tackled locally (often in partnership with local LMCs), and that a one size fits all contractual management programme does not work.

In recent times the role the CCG primary care teams plays has also been evolving.  In a system redesign programme, e.g. of long term conditions or urgent care, general practice is an essential component.  As such, the role of the primary care commissioning teams has become as much about shaping the input of primary care into these redesigns, through local enhanced services or incentive schemes, as it has around local contract management.

Within an integrated care system there is an essential need for primary care to be a core component of local redesign, particularly in a place-based arrangement.  But how will this work in practice?  Is the expectation that PCN Clinical Directors will agree changes and then ensure implementation across their practices?  Will the PCN Clinical Directors write the terms of any new local contract, agree it with the LMC, and manage its implementation with their practices?

This does not sound very realistic.  Aside from the issue of GPs writing their own contract, and the huge unwillingness there will be by PCN CDs to take on the role of contract enforcers, the continued lack of support for investment in any form of PCN management means there is simply not the capacity to do this.

Should CCG primary care commissioning teams, then, become part of local place-based arrangements?  Could they play a role there as enablers of change?

This does seem logical.  At its heart, integrated care is about providers working together to agree changes to improve outcomes, experience and value for money.  Within this model general practice needs to be suggesting and driving its own changes, not primary care commissioners.  But there is potentially an important role for the existing CCG primary care teams to work in partnership with general practice as an agent and enabler of change.  Because without this in place, how will it work?

The problem with this is one of accountability.  Who would the primary care commissioning team be accountable to?  The PCNs? The local place-based ICS Board?  The local federation?  There is no right answer, and this clearly needs some working through, but it doesn’t feel insurmountable.

The move to integrated care systems is happening quickly.  Let’s hope the same mistakes of 8 years ago are not repeated, that we don’t waste the skills and expertise we have in local primary care commissioning teams, and that primary care is supported to lead local change not be passive recipients of it.

14
jul
0

How Will PCNs Work Together?

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A new challenge has emerged for PCNs with the advent of Integrated Care Systems – that of working effectively with each other.  To date joint working between PCNs has been something of an optional extra, but the transition to the new arrangements mean firm plans need to be put in place.  How are PCNs going to make this work?

The new guidance on Integrated Care Systems states,

“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. This work is in addition to their core function and will need to be resourced by the place-based partnership.” p28

This seems to be a gentle way of saying that not every PCN can be individually represented in the place-based partnership (the local arm of the Integrated Care System).  Instead PCNs need to find a way of being able to work together and represent each other.  Bear in mind that place based partnerships could potentially be making funding allocation decisions that will impact on the whole of primary care, so getting this right feels very important.

In some places this is not going to be a problem.  Effective joint working arrangements between PCNs are in place, often via a federation or shared umbrella organisation, and those PCNs will be able to use that system within the new arrangements.  However, in other areas no formal joint working mechanism exists, and for these the challenge could be much greater.

There is an underlying issue when it comes to representation, and making it work in practice.  It relies heavily on trust.  When an individual is at a meeting, do those he or she is representing trust that individual to work in the best interest of all, or are there concerns that he or she will make decisions on what is best for their practice or their PCN? If an opportunity arises, e.g. to pilot a new way of working, will everyone receive a fair opportunity to take it, or will the representative have first choice?

Even where motives are good, how strong and effective are the communication feedback loops?  Is each PCN canvassed for their views ahead of important items being discussed and a consensus reached ahead of time, and is timely feedback on decisions made provided to all?  Or do those that are being represented feel left in the dark, without any real idea of what is being discussed let alone decided?

It is concerns such as these that lead individual PCNs to wanting their own individual representative at system discussions.

Even for those who do attend the meetings, life is not much easier.  It is hard to comprehend everything that is being discussed, given the complexity around Integrated Care Systems (which even seems to have its own language!).  Worse, many are left with the nagging sense that the decisions seem to be made outside of the formal meetings, with the meetings themselves just a rubberstamping of conversations that have already taken place.

Of course that is to some extent true.  Integrated care is about relationships between organisations, which means relationships between individuals within those organisations.  It is not as straightforward as objective discussions within a meeting environment.  This begs the question as to whether what PCNs need is not one of the PCN CDs to ‘represent’ the others, but a senior manager who can operate at the same level of as the senior leaders of the other organisations, and who can be part of the decision making both inside and outside of the meetings.

Appointing such an individual would have the added benefit of being effectively neutral across all the PCNs, as well as potentially being skilled at pre and post meeting communication.

The problem for those wanting to go down this route is inevitably one of funding.  The guidance says that this work “will need to be funded by the place based partnership” so if a case can be made there is mileage in exploring receiving funding for such an individual directly from the ICS.  While for the role to be effective a senior and experienced individual capable of operating at director level is required, it probably does not have to be full time which would bring the cost down.  And with an imminent turnover of CCG Directors as CCGs are abolished at the end of March there may be secondment opportunities worth exploring.

This is not an issue that can be ignored any longer.  Whatever the local difficulties, it is important for general practice as a whole (the guidance says the PCN representative will “represent primary care in the place-based partnership”), and so it is important PCNs are working now to establish how they will make this work.

I take a more detailed look at how to create a strong voice for general practice in my free guide, “10 Steps to a Powerful voice for General Practice”, which you can access by simply signing up to our weekly newsletter here.

7
jul
0

The Importance of Training for New GP Partners

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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.

30
jun
0

All Your PCN CD Mastermind Programme Questions Answered!

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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 31st July 2021.

More Questions?

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

23
jun
0

What do Integrated Care Systems Mean for General Practice?

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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.

16
jun
0

Do the Additional Roles Belong to the Practices or the PCN?

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One of my favourite questions for guests in the current series we are running in the General Practice podcast on the additional roles in general practice is where do they belong?  Do those in the roles feel like they belong to a specific practice, or to the PCN as a whole?

Many PCNs have already experienced turnover in the additional roles, despite the scheme only having just completed two years (and for the first year only pharmacists and social prescribing link workers could be recruited).  One of the most common reasons cited by those leaving is that they did not feel like they belonged anywhere.

It is a difficult conundrum.  The PCN is a collection of practices, and is not really an entity of itself.  It does not exist in a specific place, and is defined as much by a series of meetings and actions as by any physical reality.  So when an individual is appointed to work for the PCN it is not surprising that they can lack this sense of belonging to something.

This issue is then exacerbated because these roles in many places are very new.  Most practices are not used to working directly with social prescribing link workers or health and wellbeing coaches or physician associates (etc).  Making something new work involves change, and change inevitably leads to resistance.  So those taking up post in one of these new roles is working for the less-than-tangible PCN, and at the same time encountering push back from the individual practices within the PCN.

Those taking on these roles need somewhere safe they can retreat to, somewhere they can feel supported, somewhere they can regroup and work out a plan to win over those who have not yet understood the value they can add.  They need to feel like they belong somewhere.

What is really interesting about the responses that I have had to the question from those in roles that are clearly working extremely well is that they are not consistent about where they feel they belong.  Some respond quite emphatically that they feel like they belong to their host practice.  They feel part of the practice team, welcome in the practice, supported by the practice, but at the same time enjoy working with patients from across all the practices in the PCN.

Conversely others feel part of a PCN team.  This is particularly true where there are a number of roles working together, for example social prescribing link workers, care coordinators and health and wellbeing coaches.  They feel like they belong to the PCN team, and that this is where they get the support they need.  The team often has a number of key individuals (clinical supervisors, line managers etc) from across the practices, who enable this team to feel an integral and valued part of the PCN.

Where it doesn’t work, and where more commonly we see turnover in the additional roles, is when those in the role does not feel like they belong to either a practice or a PCN team.  Problems occur when roles are isolated, and left to try and work with each PCN practice without really being a part of any of those practices and without any peer support to speak of.

As long as the new roles feel like they belong to either one of the practices or the PCN then which is not really important.  What is important is they feel like they belong somewhere.

9
jun
0

How to Make the Additional Roles a Success

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We have a strange irony in general practice right now whereby the biggest investment into the service, the Additional Role Reimbursement Scheme (ARRS), is in many places adding to the challenges practices are facing rather than helping.

What is happening is that the burden of recruitment, line management, and clinical supervision, along with the time needed in each practice to make these roles effective, is outweighing the value the new roles are bringing.  This is then exacerbated by rapid turnover in these roles, and the need to constantly start over and over again.

I have written previously on the need for PCNs to plan for the new roles, and also on the challenges associated with introducing them.  But how can PCNs and practices turn this huge investment (£746M this year) to their advantage?

In recent weeks I have been talking to areas that have found ways of making the new roles a success.  What is becoming abundantly clear is these areas have understood that the introduction of the new roles is a change process and have treated it as such, rather than simply recruiting to the roles and expecting the benefits to automatically follow.

What does this mean in practice?

The leading thinker on change at present is Professor John Kotter.  In this Harvard Business Review Article, in addition to outlining the 8 steps of a robust change process, he states 8 reasons why change processes fail.

Read the article for yourself, but my take on the first three of these reasons, as applied to the introduction of the new roles, is as follows:

Error 1: Not Linking the Roles to the Need for Change

Practices are at breaking point right now.  The workload pressures on top of trying to operate in the environment of the ongoing pandemic are making life extremely challenging for many.  What many PCNs are doing is introducing the new roles without being explicit as to how they directly link to this challenge.  Without this link in place practices feel they are making the situation worse not better.

Error 2: Not Creating a Cross-Practice Team to Lead the Changes

The way many PCNs work is that the leadership of the introduction of the new roles is left to the PCN Clinical Director (CD).  They have a PCN meeting to gain sign up as to which roles from the list to recruit, but overseeing the recruitment process and introduction of the roles is left to the CD, who then in turn has to assign line management and clinical supervision roles out across the network.

The problem is that it is simply not possible for someone to successfully introduce a new role into a practice if they are not part of that practice.  A team is needed with a range of individuals, taken from across each of the practices, that is multi-professional (including practice managers, reception managers, nurses etc as well as GPs), to work together to lead the changes to make the new roles a success.

Error 3: Not being Clear what Difference the New Roles will Make

Kotter calls this lacking a vision.  The places where the new roles are working well have a plan in place as to how the new roles are going to make a difference.  They have created multi-professional visit teams to take the burden of visits off practices, or created multi-professional non-clinical teams that can manage the social and non-clinical work that comes into practices, or built prevention teams with a clear plan to tackle pre-diabetes (etc etc).  This is in stark contrast to PCNs who have simply identified the roles they most like the sound of and recruited to them because the money is available, but have not taken the time to create a clear plan as to how these new roles will make a difference.

These are not the only mistakes being made.  All of the errors Kotter outlines can easily be applied to the introduction of the new roles.  The key message, however, is to think of the introduction of the new roles not as a task to be completed, but as a change process that if done well can add huge value, but if done badly will probably make things worse.

2
jun
0

The Investment and Impact Fund Year 2

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Whilst we are already a couple of months into the new financial year, with so much going on it has been hard for everyone to fully get their heads round the changes to the Impact and Investment Fund (IIF) for 2021/22.  This week I summarise those changes and what it means for PCNs and practices.

I wrote last year about the Impact and Investment Fund when it was first introduced.  You will recall for the first six months of last year the funding was protected as a covid fund for PCNs.  The IIF was then launched in October, in the format of a ‘QOF for PCNs’.

PCNs are yet to receive money earned from the IIF for the last six months of 2020/21.  As I understand it once the figures have been collated nationally, and they have established exactly what an “average” PCN comprises of, PCNs will be sent a draft declaration which they will need to confirm as accurate, or appeal to their commissioner if the figures are wrong.  The amount of time it is taking to pull these figures together suggests there may be trouble ahead in getting final agreement on these figures!

Year 2 of the IIF is nonetheless underway.  The scheme works the same way as last year, with minimal changes.  The prescribing indicators have been dropped (I suspect at least in part to do with the challenges of integrating the prescribing database with the information from GP systems).  This year there are three flu vaccination indicators, the social prescribing and annual LD health check indicators remain (with adjusted thresholds), and there is a new one off indicator of “mapping appointment categories to new national categories” which needs to be completed by the 30th June.

There is £200 available per point (adjusted for list size and prevalence), with 225 points available in total.  The indicators and amounts available for an “average” PCN are below (also see the PCN DES specification Annex D, p103):

 

Indicator No. of points Upper Limit Lower Limit £ available
% patients aged 65+ who received a seasonal influenza vaccination 01/09-31/03 40 86% 80% £8,000
% patients aged 18-64 and in a clinical at-risk group who received a seasonal influenza vaccination 01/09-31/03 88 90% 57% £17,600
% children aged 2 – 3 who received a seasonal influenza vaccination 01/09-31/03 14 82% 45% £2,800
Percentage of patients on the Learning Disability register aged 14+, who received an annual Learning Disability Health Check and have a completed Health Action Plan 36 80% 49% £7,200
% patients referred to social prescribing 20 1.2% 0.8% £4,000
Confirmation that, by 30 June 2021, all practices in the PCN have mapped all active appointment slot types to the new set of national appointment categories, and are complying with the August 2020 guidance on recording of appointments 27 Binary target – all practices to achieve for PCN to receive in year payment £5,400

 

The amount available is roughly double what was available for the last six months of last year (£40,500, compared to £21,500 for an average PCN last year).  A key point to note here is that only one third of the £150M set aside for the IIF in the contract for this year has currently been allocated. The plan is to allocate the rest of it to new indicators to be introduced from 1st October (Covid permitting) with double the value of the existing indicators.  My understanding is these indicators are most likely to be linked to delivery of the new PCN specifications also due to be introduced at that time.

So by the end of the year the IIF is likely to be worth over £120k to the average PCN.  This is due to increase further to £250k by 2023/24.  During this year the IIF will overtake the core funding of £1.50 per head in terms of value to the PCN, and will continue to grow thereafter.

The flu indicators, representing 142 of the 225 points on offer, do not start until September, so at present there is relatively little for PCNs to do, other than to ensure they have effective monitoring and reporting systems in place, to try and get ahead of the social prescribing referral target, and to ensure all practices carry out the appointment mapping exercise.

But this will most likely be the calm before the storm.  The importance of the IIF may be minimal at present, but the values attached to it mean this is likely to change significantly in the second half of the year.  At that point the new indicators alongside the existing flu ones will mean the work really begins.

25
may
0

Training and Development Support for New GP Partners

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A few years ago I wrote an outline of a training programme for new GP Partners.  In recent months I have received regular requests from GPs interested in accessing the programme.  Whilst we never set it up at the time, I am working with some great partners to now make this happen.

Below is an updated and adapted version of the original blog:

“Taking on responsibility for a business, for its staff, for its performance, and for its liabilities, is a big commitment. While in the past GPs took it on because that was the established career route for them, that no longer appears to be the case. Increasingly GPs are opting out of being a partner, and taking on salaried, locum or portfolio careers. Even GPs who had previously become partners are now choosing these alternatives.

It is into this environment that we are developing a training programme for GP partners. It is for those GPs who are considering becoming a partner, want to understand better what is involved, and want to develop the skills to be a good partner should they choose to make that step. It is also for those GPs who have already made the decision to become a partner, and want training and development to ensure they can be successful in the role.

The programme will comprise of the following areas.  We will work with participants to tailor it to their individual needs through the course of the programme

Section 1: Internal – understanding the business

Success Measures: What constitutes success for the practice? Is the practice there to serve patients or to make money? What does independent contractor status really mean?

Partnership: What is a partnership; why partnership agreements are important; what makes a good partnership agreement; building a strong partnership team; “last man standing” and strategies for dealing with it.

People: How to lead people, how to manage people (and understanding the difference!); dealing with difficult people (including other partners!); staff appraisals; staff surveys; team meetings; the importance of coffee.

Finances: Partner financial responsibilities; dealing with accountants; understanding cash flow; how to manage the finances.

Processes: Appointment systems: the good, the bad and the ugly; DNAs; workflow redirection; active signposting. How to implement change within the practice.

Property: Understanding premises; types of ownership of property; leases and rent reimbursement; working with NHS Property Services.

Practice Manager: What to expect from your practice manager; how to get the best out of them; understanding the difference between the role of the practice manager and the role of a GP partner; how to know if you need to change your practice manager and how to do it.

 

Section 2: External – understanding the environment

NHS: Understanding where GP practices fit within the NHS; the different structures and types of organisation within the NHS and how they impact on GP practices.

Commissioners: Friend or foe? Understanding the GP contract and how it works; understanding the different commissioners; how to build effective relationships with commissioners.

Regulators: The role of the CQC; surviving inspections

Primary Care Networks: What is a Primary Care Network (PCN); how to build relationships with other GP practices in the PCN; overcoming history and other barriers to joint working.

Integrated Care: What is integrated care?  What is an Integrated Care System?  What does it mean for my practice?  Is building relationships with other organisations, such as community pharmacy, community trust, local voluntary organisations, local council, local hospital important? Who to prioritise; how to do it.

 

Section 3: Future – understanding the risks

Changing NHS: The changing NHS, including the new (2019) GP contract; integrated care systems; and the role of PCNs moving forward.

Strategic Change: Understanding strategic options for your practice for the future; how to develop them; how to implement them.

Practice mergers: When to consider it, when not to, and how to do it successfully.”

 

If you are interested in being part of our pilot cohort which has a maximum of 15 place available, please get in touch (ben@ockham.healthcare). The course will start in September, and will be delivered online.  We will work with this cohort to tailor the programme to the specific needs of those on the programme.  I am hugely excited about taking this forward, and I will share more details as we finalise the programme over the coming weeks.

19
may
0

How Should Your Practice Respond?

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It has been a difficult week for general practice.  The main source of the problem has been a letter from NHS England that panders to press criticism by mandating practices to “offer face to face appointments” (implying they have not), and to allow patients to choose whether they need to be seen face to face or not (“practices should respect preferences for face to face care unless there are good clinical reasons to the contrary”).

The widespread anger this letter has caused is not difficult to understand.  Many practices have been uncomfortable with virtual appointments for a long time, but the ‘total triage’ model was mandated by NHS England in the first place as a response to the pandemic.  To then be criticised on the front page of the Telegraph for using it is galling.

The workload itself in general practice has risen to unsustainable levels over the last few months, in part fuelled by the additional demand from the new routes of access.  Practices are already offering face to face appointments (the implication they are not is of itself insulting), but what this does is raise patient expectations to expect an appointment with their GP whenever they want one.  It is GP receptionists who often bear the brunt where these expectations meet reality, and in extreme circumstances can result in vandalism of practices.

This government’s biggest success has been the vaccination programme, the delivery of which has largely been down to general practice.  There is no mention of this in the letter, of the amount of additional work this has put upon practices, or even any acknowledgement of the contribution made.  Any lingering hopes that the role of general practice in the vaccination programme would change the public perception of GP practices have been sadly extinguished by this letter.

So where does this leave general practice?  What is the right way to respond?

The first thing to note is that the letter is overtly political.  The government is obsessed with access to GP practices (and has been for the last 10 years) because it understands the link between access to a GP practice (where so many of the NHS consultations take place) and the overall public perception of the NHS.

Equally the media understand this.  So a story that demonstrates there are problems with access to your GP is a story that demonstrates a government is failing in its handling of the NHS.  The Telegraph in particular has been trying to make a story about access to GP practices throughout the pandemic. Like it or not, GP practices are political footballs.

The temptation is of course to get drawn into working out how to influence the national debate.  Should there be a collective work to rule, a refusal to participate in any work beyond the core contract, or some other form of collective action?  The unfortunate reality is that for most of us engaging in the national politics around this is futile.  Clearly there is a role for the BMA and GPC in fighting the corner of general practice, but this needs to be done at a national level.  The worst outcome is to penalise your own patients and population because of national politicking.

For individual practices it is better to focus on those things you can influence, such as supporting staff, promoting thank you letters and the positive comments received, building positive local communications about the work of the practice as well as its role in the vaccination programme, and the impact you are making on local lives.  General practice remains one of the most trusted professions in the land, and local people will listen to you.

The bigger question is to work out how you will tackle the next 5 years.  The workload will continue to grow, patient expectations will continue to accelerate, and the number of GPs remains static.  Practices need a plan, because carrying on doing the same things will simply mean the pressure will get worse.  This will not be the last letter, or the last insult, or the last criticism of general practice.

Of course there is the temptation to simply walk away, and say enough is enough.  But not everyone has that option, and all that will do is make it even harder and more challenging for those left behind.  Even if that is what you want, it is better to leave with a clear plan in place so that those who remain have some hope and confidence in the future.

While the independent contractor model means there is limited protection from national and press assaults such as this one, it also means GP practices are businesses that can choose how they operate and organise themselves.  It is better to focus on what you can control and spend time working out what you can do to meet the challenges ahead.

There will always be national politics, and general practice will be part of this.  At times like this it is frustrating, disappointing and enraging.  However, channelling your energy into those things you can control, strengthening your own local communications, and planning for the future is the best way to respond.

12
may
0

5 Top Tips for Success as a PCN Manager

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Despite no funding for a manager being included within the PCN DES, the PCN manager has quickly established itself as a crucial role.  As PCNs continue to grow in terms of staff and responsibilities, so has the importance of the PCN manager.  But the role does not come without its challenges, and many who have taken it on are finding the going tough.  How, then, can PCN managers make their role a success?

I recently spoke to PCN management expert Tara Humphrey, and out of that conversation distilled 5 important actions PCN managers should take to be successful in the role:

  1. Be Clear What Success Look Like

The challenge facing many new PCN managers is the PCN into which they are arriving has often not made explicit what actually constitutes success for the PCN.  Indeed, in many PCNs, success can mean different things to different people within it.  If the PCN is not clear what success looks like, it will be impossible for the incoming PCN manager to achieve it!

The trick for the PCN manager is not to assume that simply delivering the PCN DES requirements constitutes success.  If it is not explicit, ask those in PCN what success looks like for them.  Listen carefully to the answers.  Play back what you have heard and get sign up from the PCN as a whole.

When you are clear what success looks like, use it as your guiding principle.  When faced with competing priorities or pressures on your time, use how it will impact on the success of the PCN as your way of making decisions.  This will also help you not to feel like a CCG manager or someone adding workload to the practices, but rather someone supporting them to achieve what they want with the PCN.

  1. Form a Strong Partnership with the PCN Clinical Director

The really successful PCN managers are those who have formed a strong partnership with their PCN CD, and are clear on what each of their roles are.  The two need to work as a team, playing to each other’s strengths, and compensating for each other’s weaknesses.  For example, one might be great at building relationships and communicating with the practices, while the other might be better at understanding and distilling the guidance as it comes in from NHS England and the CCG.

The PCN Clinical Director will always retain overall accountability for the PCN’s success, but what actions the PCN CD and PCN manager respectively take to ensure this success is up to them.  Key is that the two of them create a strong partnership and work together, and the better they do this the more likely success will follow.

  1. Build Strong Relationships with the PCN Practice Managers

The practice managers can make or break a PCN manager.  If a PCN manager can build strong relationships with and earn the trust of the practice managers in the PCN, and have open channels of communication through them into each of the practices, their chances of success are really high.  But if they fail to get the practice managers on side they will really struggle to be successful in the role.

I have already seen a number of instances where PCN managers have had to leave their roles because they lost the confidence of the practice managers.  If the practice managers are regularly complaining about the PCN manager to their GPs, who in turn pass on these concerns to the PCN CD, the position is more or less unsustainable.

  1. Decide Whether to Work With or Round the Difficult Practice or GP

There is always one!  I am yet to meet a PCN where there was not at least one GP (or more often than not a whole practice) who is at best disinterested in the PCN and at worst obstructive to whatever the PCN is trying to achieve.  For the PCN manager there are two choices.  Do they invest significant time and effort into getting this GP/practice on side, so that the work of the PCN can progress?  Or do they focus their attention on the other, more willing GPs and practices to ensure that any attempts to derail progress are not successful?

Each situation is different, and the right approach to take in any individual PCN will depend on the local circumstances, but what the PCN manager has to do is work out which tactic is best and then make that approach work.

  1. Communicate More Than You Think You Need To

For a PCN to be successful, it needs to do two things.  First, take actions and make progress towards its goals, and second communicate these actions and successes to its members.  Most PCN managers understand and do the former, but then completely underestimate the importance of the second.  The result is those in the PCN are generally not aware of just how much the PCN has achieved.

As a PCN manager your days are spent on PCN business.  It is easy to think everyone else has the same level of knowledge of what is going on as you do.  But others in the PCN have busy other jobs and are not as immersed in it as you are, and they quickly forget what the PCN is up to.

Communicating via a once a month PCN meeting is not enough.  There needs to be WhatsApp groups (or equivalent) and a regular email update/newsletter (probably weekly) as a minimum.  Some PCNs have gone as far as setting up their own podcast simply to communicate internally where they are up to.

Success breeds success, and using communication to ensure that not only is the PCN successful but that it is perceived as being successful is vital for future and ongoing success.

 

5
may
0

Does Your PCN have a Financial Plan?

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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.

28
apr
0

How to be an effective PCN Clinical Director

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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 3rd 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!

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apr
0

Do you really trust your team?

Posted by Blogs, The General Practice BlogNo Comments

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.

14
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The trouble with conflict in General Practice? There’s just not enough of it.

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A busy practice is wondering why it is struggling to recruit more doctors.

The team is lovely, ‘we all get on really well, never a cross word’.  The practice manager agrees, ‘the partners are just really nice’.

The problem is they’ve been trying to get their document management workflow right for years but no-one’s on the same page. The doctors are staying later and later just to get everything done and even though they’ve been offered half a clinical pharmacist by the PCN they’re a bit unsure about how it will work for them.  When they tried it before, the person they appointed moved on after three months.

In this day and age, being ‘nice’ just won’t cut it for your team.

You see the problem I’ve seen the most in practices is not out and out war between the partners (though that definitely exists!) but the problem of people being too nice and a fear of conflict, which produces artificial harmony.

We all know that destructive conflict can cause untold damage to teams and organisations and is to be avoided at all costs.  However we are in danger of throwing the baby out with the bathwater when we are so frightened of destructive conflict that we avoid having any constructive conflict that will help us to debate and solve problems and ultimately work better together.

If we avoid conflict, what happens? People ignore changes that are being implemented, don’t use the new systems and processes designed to improve things and carry on with business as usual. Bad behaviour is not addressed, groupthink happens and often the loudest and most senior (though it doesn’t always have to be) voice in the room gets their way.

‘For good ideas and true innovation, you need human interaction, conflict, argument, debate.’ Margaret Heffernan

How many ideas have been lost, initiatives gone untried, and changes failed because we didn’t have the constructive debates and disagreements needed to come up with better solutions?

With artificial harmony it’s not that people don’t disagree, it’s that they disagree and just don’t tell you. Then, if a decision is made that they disagree with, they simply won’t commit to doing it. (Think about how many times something was discussed and ‘agreed’ in a partnership meeting that people just don’t do).

So this fear of conflict leads to a lack of commitment – the second and third dysfunctions of a team as described in Lencioni’s ‘5 Dysfunctions of a Team’. This in turn leads to avoidance of accountability and inattention to results which will affect workload, performance and even patient outcomes.

So how exactly do we increase the amount of constructive conflict in our practices?

You need to start with building vulnerability-based trust. This is where you can trust that if you disagree over something, the relationship will still be OK. Trust that you can fail, do something wrong or just have a bad day and you’ll be forgiven. In short, it needs to be SAFE to speak up and to disagree. This is the basis of psychological safety.

 

Here are some suggestions about how you can increase the constructive conflict in your practice:

  • Mine for conflict. In every meeting, in every discussion, ask every person to tell you 3 reasons why what has been suggested won’t work, or 3 potential problems / barriers or challenges they can see. Constantly ask people ‘what am I missing here? What are the downsides to this?’
  • Assign different roles in a meeting – make one person ‘Devil’s Advocate’ (to disagree about everything!). Make one person the ‘Unconditional Supporter’ (to agree), and one person ‘Switzerland’ (to be completely neutral). Make sure you swap these roles around regularly so that one person doesn’t get stuck as the Devil’s Advocate all the time!
  • Listen and ask questions. Give people ‘permission’ to disagree. Thank people for their contributions
  • Build up trust within your team. Get to know people, have coffee together, understand where they’re coming from. Model vulnerability; admit when you’ve failed and when you’re having a bad day.

So next time you’re feeling frustrated and stuck, ask yourself, are we being ‘too nice’ here? How can we help everyone feel able to get their ideas and opinions on the table? You might just get a pleasant surprise.

 

Dr Rachel Morris, April, 2021

Further resources:

 

Want to learn more about how to increase trust and psychological safety within your team? Would you like to get a happy, thriving team at work without burning out yourself? Join Rachel in 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. PLUS gain exclusive access to Ben and Rachel’s very special bonus course ‘How to work together across practices and networks: 6 mistakes leaders in healthcare make and how to avoid them’. This very special offer for Ockham Healthcare ends on the 2nd May – click here for more information.

24
mar
0

What did the GP Forward View Achieve?

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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

17
mar
0

Who is looking after General Practice?

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This pandemic has not been just one big challenge, but rather a whole series of different challenges over an extended period of time.  As we move into yet another phase, and the next set of challenges, where does the energy come from to keep going?

At first there was the arrival of the pandemic itself, changing the operating model and moving to remote working, and putting systems and processes in place for managing patients presenting with Covid symptoms.  Then we had to work out how to do this alongside the normal work of general practice.  Then we had to introduce a vaccination programme, which has been all consuming and itself a series of different challenges (different vaccine types, care homes, housebound, practice dispersal etc etc).

One year in, we are once again moving into a new phase and a new set of challenges.  Some of the core services (such as QOF) that were put on hold are restarting.  The vaccination programme continues.  The work of PCNs accelerates, as the ARRS nearly doubles in size and the move towards integrated care means PCNs have to start to play an important role in influencing the system as whole.

But are we ready for more challenge?  How do we find the energy and personal resources to cope with and manage more change, more disruption, and yet more new ways of working?

We have not been good in the NHS at looking after the people who work in the service, or indeed at looking after ourselves.  We have known for a number of years that most GPs are looking to reduce the number of hours they work, and a large percentage of those who can are planning to retire in the next five years.  It is not just GPs; many practice managers and other members of the practice team are also looking to leave.  The recent pay offer for NHS staff and the freeze on the lifetime pension allowance is not going to help.

The continual wave after wave of challenges the pandemic is creating has made this situation more critical than ever.  If we do not take time now to look after ourselves, and look after the people we work with, it wont be long before the exodus of people out of general practice reaches unprecedented levels.

We have to prioritise our staff and ourselves.  The good news is that there are actions that we can take.  In this week’s podcast I talked to resilience expert and GP Dr Rachel Morris.  She outlined a range of tools, techniques and approaches that can all help with personal and team resilience.

It seems to me that the starting point is deciding that looking after ourselves and our teams is the priority.  We cannot rely on or even expect other people, or the wider NHS, to do that for us.  Most people working in general practice have spent a lot of time doing whatever has been needed to meet the different Covid challenges.  Going forward the only way general practice is going to be in a position to serve its local populations is by ensuring it takes time now to invest in itself and the people who work there.

10
mar
1

ARRS Roles: Planning for Year 3

Posted by Blogs, The General Practice Blog1 Comment

We are about to embark on year 3 of the Additional Role Reimbursement Scheme (ARRS), through which the PCN DES funds additional roles for individual PCNs.  How can we take the learning from the first two years and build it in to our planning for next year?

The first year of the ARRS was relatively quiet, as PCNs were only allowed to employ a pharmacist and a social prescribing link worker.  Last year the scheme took off, in part because the list of different roles was expanded to 10, and in part because 100% (as opposed to 70%) of the salary costs were reimbursed through the scheme.

The investment into roles through the scheme continues to increase significantly into year 3, with the total investment reaching £746M nationally.  Many PCNs will be in a place where they can afford 10 or even more staff with the funding available. This number will continue to rise for the next two years.  What this means is PCNs have to move from considering the ARRS staff on an individual basis to thinking about all of the roles collectively as a team.

I have written previously about the challenge of introducing the new roles.  This challenge just gets greater as the number of roles increases.  We are now at a tipping point where the overall approach needs to change.

Any business that employs 10 or 20 staff would put a business plan in place.  Having a plan is what is now required for PCNs.  The plan needs to contain (as a minimum) the following 4 elements:

  1. Team Objectives

PCNs need to clarify exactly what the objectives for the ARRS team are.  How will the PCN know at the end of the year whether the new team has been a success?  How will the team itself know?  How will the practices know?  Agreeing objectives for the team will help everyone, and help move the PCN away from a mentality that it is recruiting these roles simply because the funding is available.

  1. Team Structure

The retention challenge for these roles is something I have already written about, despite the recruitment only really taking place in earnest over the last 9 months.  It is clear the individuals in these roles need to feel part of a team.  At the same time, practices cannot simply absorb the extra work of looking after these roles, and asking them to do it means in many cases it simply does not happen.

My sense is most PCNs will need to create an overall ARRS team.  Very large PCNs can probably create more than one team, such as a pharmacist team and a social prescribing team, but the majority of PCNs will need one team so that the individual Health and Wellbeing Coach (for example) does not end up being isolated.

The team will need a leader.  It needs to be someone’s job to be responsible for the overall ARRS team.  This does not mean line managing every member of the team, but it does mean responsibility for ensuring the team is functioning effectively, delivering on its objectives, has effective communication across it, and that any issues that arise are dealt with.  This could be the Clinical Director or PCN manager, but someone needs to take on this role.

The team needs to have a structure.  Moving beyond 5 or 6 members of the team means that there needs to be levels within it, e.g. one of the pharmacists managing the other pharmacists, a senior link worker managing the other link workers etc.  Planning the structure, thinking about individual advancement, making the team more self-sufficient are key aspects of this part of the process.  No structure means as more staff are recruited, the burden simply becomes greater on a relatively small number of individuals.

  1. Team Support

The key retention question for the PCN is how will this team be supported?  The provision of support is critical to getting the most out of them.  There are plenty of examples up and down the country of either ARRS staff such as Physician Associates carrying out low level work because no clinical support is being provided, or of staff such as social prescribing link workers working to other agendas because what support there is is provided outside of the PCN.

Increasingly there are opportunities (e.g. for pharmacists here or physician associates here) to ensure ARRS staff receive the training they need.  We are beginning to understand better how work needs to be organised to ensure ARRS staff can be effective (e.g. for FCPs here).  The PCN plan needs to be explicit about exactly how the ARRS staff will be supported.

  1. Team Finances

As the team expands the financial model of matching the monthly cost of the ARRS staff against the reclaimable allowance is no longer sufficient.  This is an important element of the financial plan, but cannot be it in its entirety.

The ARRS team are a (funded) investment in the wider work of the PCN.  There are wider costs beyond those which can be reclaimed, e.g. clinical supervision, line management, estates costs, training costs.  PCNs also need to be mindful of potential VAT costs as they are likely to exceed the £85,000 VAT threshold, and of the need for a fund to cover potential employment liabilities.  Equally, income can come from other sources such as CCG/HEE/ICS funding pots, PCN core and development funds (etc), as well as benefits in kind provided to practices (e.g. support for vaccination services, a home visiting service, support with the delivery of enhanced services etc).  There are also future opportunities on the horizon, such as support with the delivery of extended access.

The funding model is not perfect, but for the ARRS team to be effective a financial plan for the team as a whole needs to be put in place.  This is more important this year than it was last year, and its importance will continue to increase year on year as the total amount of ARRS funding received (and associated costs) grows.

 

The plan does not need to be long or complicated.  But spending some time and energy now in putting a plan together will put the PCN in a much stronger position for making the most of the opportunity of these new roles in the year ahead.

3
mar
1

Does Integration Really Mean Centralisation?

Posted by Blogs, The General Practice Blog1 Comment

I wrote last week about the new White Paper published by the government, and what it means for general practice.  My sense at the end of the White Paper is that I am less clear now than I was before as to what exactly is meant by “integration”.  Does it mean removing the barriers between organisations to enable joined up care, or does it in fact mean a further centralisation of control?

I understand the logic of integration, and why it is perceived to be a ‘good thing’.  Years of an internal market have created divisions and rivalries within the health service, and led to behaviours focussed on the needs of individual organisations rather than necessarily what is best for the patient.  It makes sense, then, to take steps to remove these artificial barriers created by the system, and for the organisation of care to be centred on what is best for patients.

There is, however, a difference between removing the barriers that have prevented health and social care professionals from working across organisational boundaries and centralising control into single organisations.

The new statutory NHS Integrated Care System (ICS) bodies will be given more formal power, “In order for ICSs to progress further, legislative change is now required to give ICSs stronger and more streamlined decision-making authority” (White Paper 5.4).  Further “each ICS NHS body… will be directly accountable for NHS spend and performance within the system” (6.18 f).  The NHS is well known for its mindset that accountability cannot be exercised without control.  Indeed, the system’s experience of the regional tiers of NHS England points very much to the fact that centralised control is something NHS England is extremely comfortable with.

All organisations within the NHS will not be merged into these new ICS bodies.  How, then, could control be exercised by the new system?  Well there are “several further changes to reinforce or enable integration” (the actual words used, 5.13 of the White Paper), one of which is a new “duty to collaborate” (3.11) imposed on all organisations across the system.  It does not take a huge stretch of imagination to envision a situation where any organisation not complying with the central diktats of the new ICS are taken to task for failing to comply with the new duty to collaborate.

The White Paper does talk about “the primacy of place” (6.5), and by place it means local areas within an ICS, but it only goes on to say that place is important, and not how this primacy should be effected.  Instead the government is not, “making any legislative provision about arrangements at place level – though we will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14).

Worrying, then, that a centralist-minded ICS would be able to set up its own arrangements for how arrangements in local “place” areas will work, with as many control mechanisms as it likes.  The argument is that by not legislating the arrangements that work best in any local area can be made, but that does leave it wide open to local interpretation/abuse.

We are therefore left with a situation, embedded by a new legislative framework, that seems designed to bring about integration not through relationships but through a system of centralised control.  How it works in practice will be dictated by the way NHS England behaves with the new ICS’s, and how the local leaders then operate within their own area.

Now I am generally a glass half-full individual, and of course there will be local leaders who focus on empowering and enabling local teams.  But I suspect this will be the exception rather than the rule, and so all of this leaves me feeling less than optimistic about the future.

24
feb
2

What does the new White Paper mean for General Practice?

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White Papers are not known for their readability, and at 80 pages long it easy to understand why the White Paper published on the 11th February has not made it to the top of the reading list of GPs busy dealing with the pandemic.  But how important a document is it, and what implications does it have for general practice?

The document signals three changes important for general practice:

  1. The Primacy of Integration
  2. Integrated Care Systems to become Statutory Bodies
  3. Locally Determined Place-based Arrangements

 The Primacy of Integration

At the core of the changes proposed is a shift away from the internal market and towards joined up, or integrated, care.  The aim is to continue to bring different parts of the systems closer together, and to support “GP and healthcare specialists to work together to arrange treatment and interventions that either prevent illness or prevent their conditions deteriorating into acute illness” (4.2).

Integration does not mean merger.  “While NHS provider organisations will retain their current structures and governance, they will be expected to work in close partnership with other providers and with commissioners or budget holders to improve outcomes and value.” (6.8)

There is, however, a new duty to collaborate. “This will require health bodies, including ICSs, to ensure they pursue simultaneously the three aims of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.” (3.11).  One assumes this will equally apply to general practice.

The expectation in recent years has been for GP practices to work together and in partnership through Primary Care Networks (PCNs).  While the White paper says very little directly about PCNs, it certainly signals integration as the direction of travel moving forward.

Integrated Care Systems to Become Statutory Bodies

Integrated Care Systems (ICS’s) are not new, as most areas already have one, and the White Paper is very much about legislation catching up with what it already happening.  However, as a result of the proposed legislation the ICS’s will become statutory bodies.

Each ICS “will be made up of an ICS NHS Body and a separate ICS Health and Care Partnership, bringing together the NHS, local government and partners. The ICS NHS body will be responsible for the day to day running of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the systems’ health, public health, and social care needs.” (3.9).

Why separate the ICS NHS body and the ICS Partnership?  The White Paper explains that the creation of an ICS NHS body is needed to, “merge some of the functions currently being fulfilled by non-statutory STPs/ICSs with the functions of a CCG. We aim to bring the allocative functions of CCGs into the ICS NHS body so that they can sit alongside the strategic planning function that we would like the ICS to undertake” (5.8).

Effectively then the role of CCGs become subsumed under the ICS NHS statutory bodies, who will take on both responsibility for allocating NHS money and the commissioning of general practice. However, interestingly, “It will not have the power to direct providers, and providers’ relationships with CQC will remain unchanged.” (6.15 e)

So the days of general practice being responsible for NHS money – the claim made when CCGs were introduced – will formally be over with the introduction of the new ICS NHS bodies.  General Practice will still have a say, however, as, “Each ICS NHS body will have a unitary board, and this will be directly accountable for NHS spend and performance within the system, with its Chief Executive becoming the Accounting Officer for the NHS money allocated to the NHS ICS Body. The board will, as a minimum, include a chair, the CEO, and representatives from NHS trusts, general practice, and local authorities, and others determined locally for example community health services (CHS) trusts and Mental Health Trusts, and non-executives.” (6.15 f)

In addition to this statutory board, ICSs and NHS providers can create joint committees and delegate decisions to them. At the same time NHS providers can form their own joint committees.  These are relevant for general practice as, “Both types of joint committees could include representation from other bodies such as primary care networks, GP practices, community health providers, local authorities or the voluntary sector” (5.26).

It will be important for general practice to ensure it both has representation and get its representation right on both the local statutory boards and joint committees.

Locally Determined Place-based Arrangements

An important term used in the White Paper is that of “place”.  By place it means local areas within a larger ICS, “Most usually aligned with either CCG or local authority boundaries… Many provider organisations and groupings of organisations such as primary care networks look to their ‘place’ as their primary focus” (6.5).  Place, then, is not a PCN, but the local area within which a PCN operates.

The White Paper does not propose any legislative arrangements at a place level, although they, “will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14) – i.e. expect guidance to come.  Local Authorities will have a big say in these place-based arrangements, which include aligning ICS allocation functions (i.e. where the money goes).  Health and Wellbeing Boards are explicitly recognised as having “the experience as place-based planners” (5.11), and so will feature in the local arrangements.

Local place arrangements may well end up being the ones that impact general practice and PCNs most.  Individual areas will have more of a say as to how these end up as they are outside of the scope of the new legislation, so it is important GPs and PCNs start to influence now how these develop locally.

 

Overall the White Paper signals a continuation of the changes already started across the NHS.  It does means a new contract manager for general practice (the new ICS NHS body), but more importantly it requires general practice to work in partnership with other organisations, and those partnerships will be pivotal to its future success.  Little if anything is said in the White Paper about PCNs and their future role in the new system, but everything suggests PCNs will be the key enabler of these partnerships.

17
feb
0

The Changing Face of At-Scale General Practice

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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.

10
feb
0

Could the Vaccination Programme have been Organised Differently?

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Last week I considered whether the impact of the vaccination programme might end up being too much for general practice, as a result of the financial and personal challenges that it has entailed.  One of the questions that this provoked was what would I have done differently given the chance to run the national programme?

Of course no one has the freedom to run the national programme.  Even our national primary care leads are constantly negotiating with (and directed by) their own political and NHS masters.  But even with that in mind the national approach could have been different.

The national approach has been characterised, I think it is fair to say, by control.  It started with the insistence that general practice sites were organised via “PCN groupings”.  Why was that?  Well in part it was because of the logistics of the Pfizer vaccine.  But this was never going to be the only vaccine, and the logistics were always likely to change, but there was never a commitment to work through individual practices.  PCN groupings were to be the delivery unit.

The fact is c1000 PCN groupings are easier to control than over 7000 practice units.  Supply can be controlled, delivery can be controlled, cohorts can be controlled.  While the vaccination service has technically been delivered via an enhanced service contract, in reality it has been managed as an NHS directly delivered service.  The daily requirements to provide information, the strict controls on what is and isn’t allowed, and the regular interventions from above into local sites are all testament to that.

This does feel like a taste of the future.  PCNs will increasingly be the ‘go to’ units of general practice, rather than individual practices themselves.  In part this is because it makes ‘integration’ between general practice and the rest of the NHS easier to achieve (e.g. the arrangements for mental health workers in next year’s ARRS scheme), but in part it is because it puts general practice more within the control of the NHS.

Could things have been done differently?  Or did the overriding requirement for speed and rapid mobilisation mean the approach built around national control taken was the only realistic one available?

I think things could have been done differently.  The approach could have devolved more control to local areas.  Local areas could have been given a clear set of outcomes to achieve within a set timescale and a set amount of funding, and could have been allowed to develop and implement tailored solutions for their local areas.   Each area could have created its own, joined up mix of PCN, practice, and mass vaccination sites (or indeed other types of site), that could have worked together to ensure whole population coverage.

We are in a situation where PCN sites, mass vaccination sites and pharmacy sites feel more like they are competing against each other than working together to achieve whole population coverage.  Separate national implementation teams has led to local confusion rather than a joined up approach. If local areas had been able to design their own mix of service offerings everyone could have understood their respective roles and worked together as a local team.

Local areas could also have tailored their approach according to their own local strengths and weaknesses, and challenges.  Rural areas could have taken different approaches to more densely populated urban areas.  Mass vaccination sites could have been targeted where PCN sites found it more difficult to mobilise.  Most importantly, sites within local areas could have actively supported each other, as different members of the same team.

I know it is easy to criticise, and am cognisant of just how successful the vaccination programme has ultimately been so far.  But we are on the verge of a shift in NHS policy towards integrated care systems.  The danger is that these systems, and PCNs within them, simply become different units through which central NHS exercises top down control.

For integrated care and these new ICS systems to really work they need to be locally owned and led, and freed up from top down imposition.  The concern the national vaccination programme highlights is that local freedom and true integrated working will remain secondary to top down national control.  The cost of that approach is things that do not make sense at a local level as well as an unsustainable level of pressure on individuals.

3
feb
0

Will the Vaccination Programme prove to be too much for General Practice?

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A GP posted this message on twitter last weekend:

“Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (you can find it here)

It is an interesting prediction.  I would say general practice is currently divided into two groups.  There are those sites that have a vaccination model that is working well, has a team that is functioning effectively and are not only delivering the vaccine but also deriving huge satisfaction from doing so.

Sadly this group do not seem to be in the majority.  The second (larger) group are those who are both struggling to make the vaccination model work financially, and personally finding the whole process physically and emotionally exhausting.

The financial challenge noted in the tweet comes for a number of reasons.  The Pfizer vaccine is much more expensive to deliver (because of the need to dilute the vaccine, to put a 15 minute observation period in place for those receiving the vaccine, and to staff clinics at incredibly short notice).  There is no additional payment that takes this into account.

The housebound patients simply cannot be vaccinated within the £12.58 available.  Even if the team delivering the vaccinations can be funded (not possible if a GP carries them out), there is no way of funding all of the additional work required such as carrying out the training, gaining consent, validating the Pinnacle records etc etc.

Then there are all of the unseen costs.  Finding staff to book patients at short notice, even on the day of clinic and while the clinic is still running.  Bringing staff in on a Sunday because of an insistence that all of this week’s vaccines are used this week.  Managing the complaints because of the national control-freakery that is being applied to any messaging.  Communicating with practices and GPs who are not crazy enough to engage with WhatsApp groups that spew hundreds of messages a day, but are the only way of finding out what is going on.

Et cetera, et cetera.

If it does come to pass that, once all of the housebound and elderly are vaccinated and the Oxford AZ vaccine is much more widely available, primary care sites are stepped down for other sites, it will genuinely be one of the most galling financial kicks in the teeth general practice has ever experienced.

However, the personal loss for many of those leading the vaccinations is far greater than any of the financial challenges.  It is hard to overstate how all-consuming leading the vaccination process has become for many.  It is 7 days a week with no respite.  There is the weekly wait to find out what vaccines will be arriving, with painful recent scars reminding these leaders not to book anything until national confirmation is received.  Then there is the mad scramble to staff rotas and find patients for the clinics.  Then there is dealing with the inevitable change or late delivery, and having to absorb all of the local patient and staff unhappiness this creates.

For many vaccination leaders their life is on hold.  On top of the clinic challenges, there come new challenges every week – changes to the second vaccine regime, delivering to care homes, to the housebound, changes to Pinnacle, the emergence of a local mass vaccination centre (etc) – all topped with constant pressure from above to do more, faster, better.

The staff they are leading struggle with the pace, but the leaders have to push forward.  The local practices who are not involved push them from the sides.  It is the leaders who bear the brunt of the blame for national rules that don’t make any sense but can’t be broken, like which cohort can be done when, and why vaccine can’t just be given to local practices to administer themselves.

These leaders are PCN CDs, GP partners, PCN managers, practice managers.  They are our local leaders of general practice.  And if not already then certainly at some point soon they will need a break.  Many will simply not want to return.  They won’t stop until the job is done, but I understand a message that says once we get there enough will be enough.  And what then?  Who will pick up the pieces?  What state will general practice be in?  Will it all have been too much?

27
jan
0

The 2021/22 GP Contract

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NHS England published a letter on the 21st January, entitled “Supporting General Practice in 2021/22”.  The letter states NHS England and the GPC have agreed that, “too much remains unclear to confirm contractual arrangements for the whole of 2021/22”, and so the letter is intended to provide what certainty they can at this point given the pandemic.

The letter reinforces what we already knew, primarily that the majority of the additional investment into general practice is coming via the PCNs.  This primarily takes the shape of the Additional role Reimbursement Scheme (ARRS), where the total pot has been increased from £430M to £746M.

There are some interesting developments of the ARRS.  The most helpful is that those in London can now offer the same inner or outer London salary weighting as other NHS organisations (although they are still restricted to the same total pot).  Three new roles have been added: paramedics, mental health practitioners, and “advanced practitioners”.

PCNs have been looking forward to the opportunity to employ paramedics from April since it was announced last year that they would be able to do so.  There is a nasty sting in the tail in the guidance however,

“Where a PCN employs a paramedic to work in primary care under the Additional Roles Reimbursement Scheme, if the paramedic cannot demonstrate working at Level 7 capability in paramedic areas of practice or equivalent (such as advanced assessment diagnosis and treatment) the PCN must ensure that each paramedic is working as part of a rotational model with an Ambulance Trust” p7.

This theme of other NHS organisations bringing their weight to bear on the introduction of the PCN roles is also reflected in the new mental health practitioners.  Here there are even more complicated arrangements at play,

“From April 2021, every PCN will become entitled to a fully embedded FTE mental health practitioner, employed and provided by the PCN’s local provider of community mental health services, as locally agreed. 50% of the funding will be provided from the mental health provider, and 50% by the PCN (reimbursable via the ARRS), with the practitioner wholly deployed to the PCN. This entitlement will increase to 2 WTE in 2022/23 and 3 WTE by 2023/24, subject to a positive review of implementation.” p3.

Can the ARRS funding really be counted as funding for general practice if the funding is to be used for staff that are to be employed by the local community mental health provider?  It is a worrying precedent that has been set against the main source for investment into general practice.  It will be interesting to see how PCNs react to this, how keen they are to take up this offer, and what pressure is brought on them if they decline.

In better news the 4 outstanding PCN DES specifications will not be introduced at the start of 2021/22, with an implementation agreed once (if) the Covid situation scales down.  There is no mention of the existing 3 specifications and how they will be monitored through the year – something which varies considerably across the country.  The transfer of extended access will now take place in April 2022 (a more definite statement than the previous “from” April 2022), with the specification to be published this summer (i.e. September).

The Investment and Impact Fund (IIF) will continue.  The existing indicators of seasonal flu vaccinations, social prescribing referrals and LD health checks will continue (thresholds to be determined), which I assume means the prescribing indicators will not.

Finally QOF will remain broadly the same next year as this year.  A vaccination and immunisation domain will be added, adding £60m from the replaced childhood immunisations DES, there will be no new quality improvement modules but LD and supporting early cancer diagnosis will be repeated from this year, and £24M is being added to strengthen SMI physical health checks.

In summary then, no huge surprises, some minor disappointments, but on the whole a pragmatic approach to keeping the focus on the challenge that is front and centre right now of dealing with the pandemic.

20
jan
0

Should we Stop Vaccinating While Others Catch Up?

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We are at a difficult stage of the vaccination programme.  Some sites started in December, and have been able to largely complete the vaccination of cohorts 1 and 2 (care home residents, those aged over 80, and frontline health and social care workers).  Others have only just received approval for their local site to begin vaccinating, and are only now able to make a start on these priority cohorts.

The challenge is whether the sites that have completed the initial cohorts should carry on with the next cohort (the over 75s), or whether they should be stopped while other areas catch up?  By the time you read this the next cohorts are likely to have been announced, but at present strict national rules mean any area that has completed cohorts 1 and 2 is experiencing heavy pressure not to make a start on cohort 3.

The Joint Committee on Vaccination and Immunisation (JCVI) is clear that the priority for the vaccination programme is the reduction of Covid-19 mortality and morbidity, and the protection of health and social care staff and systems.  The age based strategy in place has been selected as the best option for preventing morbidity and mortality in the early phase of the programme, because “Current evidence strongly indicates that the single greatest risk of mortality from COVID-19 is increasing age and that the risk increases exponentially with age” (p4).

The strategy is clear.  So if the constraint in the system is the supply of vaccine it makes perfect sense that the supply should now be prioritised to those areas that are catching up and still have over-80s to vaccinate.  It is up to the national team who decide who is receiving supplies to ensure it goes to those sites.

The complexity comes when the constraint is not supply but delivery capacity/capability.  If a site has completed cohorts 1 and 2 and receives a supply what is it to do?  The national mandate is that this site must now help other sites to deliver cohorts 1 and 2.  This is sensible, but there are two problems with this.  One is geography – how practical is it for the over 80s to travel to an area that is further away to receive the vaccine; and the other is logistical – the Pfizer vaccines have to be used within a very short number of days, and so delays in booking patients leads to a much higher risk that the vaccines will be wasted.

Many sites have been scrambling around for patients to ensure that vaccine isn’t wasted at the end of a session.  There are reports that some sites have not been able to use all their vaccine because they have not been able to find people from the right cohort in time.

To an outsider this seems strange – surely no one would let any vaccine be wasted?  But there is heavy system pressure applied to sites about not vaccinating outside of the allowed cohort, even after Pfizer vaccine has arrived on site and the clock has started ticking.  Threats are made that sites supplies will be cut off if they go outside the cohort.  So some vaccine has been wasted.

There needs to be a balance between striving to achieve the strategy of delivering the vaccines in priority order and a pragmatism of applying this goal so that we make the most of the vaccines we have.  The JCVI itself advised that,

“Implementation should also involve flexibility in vaccine deployment at a local level with due attention to… vaccine product storage, transport and administration constraints… JCVI appreciates that operational considerations, such as minimising wastage, may require a flexible approach, where decisions are taken in consultation with national or local public health experts.” (p11)

It does not feel like we have got that flexibility in the system right yet.  As ever, the top down nature of the NHS is resulting in local inflexibility when flexibility is required.

If supply is not the constraint and some areas can go faster, and cannot for geographical and logistical reasons help other areas, surely it makes sense to let them vaccinate their local population as quickly as possible (in cohort order)?  Holding back supplies so that we all move at the pace of the slowest does not feel like an appropriate response to the crisis we are all currently in.

This is only the first time we are moving from one cohort to another; there are many more such movements ahead.  General practice has stepped up and is doing an amazing job of mobilising and responding to the call.  The numbers already vaccinated is  a testament to this response.  Let’s not let system bureaucracy impede the incredible effort that is underway.

13
jan
0

What to Make of the NHS England “Freeing up Practices” Letter

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Last week, on the 7th January, the national primary care team wrote a letter to practices entitled, “Freeing up practices to support COVID vaccination”.  There is no question GP practices are struggling right now, so how helpful was this letter, and does it go far enough?

The letter follows a previous letter written at the start of the second lockdown in November, which headlined with an announcement of £150M of additional primary care funding.  The core message of this letter was that, unlike the first wave of Covid, GP practices are very much expected to stay “fully open” this time round.  The additional funding was to enable “expanded capacity”, and to be able to deliver (on top of day to day work), extra work including:

  • Supporting the establishment of a Covid oximetry at home model
  • Identifying and supporting patients with long Covid
  • Supporting clinically extremely vulnerable patients and maintaining the shielding list
  • Making inroads into the backlog of appointments including for chronic disease management and routine vaccinations and immunisations

As a result the £150M has been primarily deployed to support additional work in general practice, rather than to provide any extra support for the work currently being carried out.

Two months later we are at a point where the pressure of the pandemic has significantly increased.  Practices are having to juggle staff sickness and isolation alongside skyrocketing demand.  At the same time the pressure is on from all sides for practices to carry out an extremely challenging Covid vaccination programme, as well as well as completing the biggest ever flu vaccination programme.  This is before getting started on the list of extra work from the November letter.

And so it was into this context that last week’s letter landed.  There is no question that the financial protections it contains were very much needed.  The minor surgery DES, the QOF QI domains and the 8 prescribing indicators in QOF are all now income protected until the end of March.  I think just seeing something that recognised the need for additional support prompted an initially positive reaction from many.

Non-essential locally commissioned services are suspended, although there is no guarantee of income protection.  Instead “budgeted payment against these services should be protected to allow capacity to be redeployed”, which undoubtedly will mean some CCGs interpret this as local income protection while others make additional requirements of practices against it.

PCN CD funding is (rightly) increased from 0.25 WTE to 1 WTE in recognition of the complexities of the Covid vaccination response.  This can “be flexibly deployed by PCNs” – it will be interesting to see how this works where one PCN is leading on behalf of a number of PCNs.

The other main announcement was that extended access funding won’t be shifting to PCNs before April 2022.  You would think that “repurposing extended hours and access capacity to support the vaccination programme” would actually be easier once the funding moves across to PCNs, but given everything currently happening I can see that many PCNs would struggle to put effective new arrangements for extended access in place any time soon.

My sense is that when you dig into the detail of the letter it does not acknowledge the reality of the additional pressure currently on practices as a result of both managing Covid patients and the demands of the vaccination programme.  If the national aim is really to free up practices to support Covid vaccinations, I would suggest what is also needed is:

  • The £150M announced in November is distributed to practices to enable them to manage the current demand rather than to create additional work for practices
  • There is a national mandate that the income from locally commissioned services is protected for practices by CCGs
  • PCNs are allowed to flexibly deploy the ARRS underspend to staff vaccination centres. The requirement for six month minimum contracts limited to the staff roles identified in the ARRS list feels like such a wasted opportunity.
  • National financial commitments are made to practices that go beyond March. The vaccination programme will take at least six months (and longer), so surely arrangements need to be put in place now that reflect that.

The ask of primary care is really significant at present, and practices up and down the country are going above and beyond to meet these challenges.  But practices remain independent businesses faced with unprecedented operational and financial upheaval, and my sense is more active support for practices needs to be provided to go alongside the demands being made of them.  Without it the current situation may not be sustainable.

16
dec
1

My 2021 Prediction: How PCNs will change

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As this is my last blog of 2020 (we are going to give you a two week break from the podcast and blog over Christmas!), I thought I would share what I foresee on the horizon for PCNs next year.  I am of course aware that predictions are a mug’s game (who could have predicted how this year would turn out?), but I always find it helpful to think through what might be coming up ahead.

My main prediction for 2021 is that there will be a move towards smaller PCNs.

Normally in the NHS, we like to start small and then merge organisations into bigger and bigger entities.  Those with longer memories will recall that multiple Primary Care Groups became a smaller number of Primary Care Trusts (PCTs), and the number of CCGs has been on the decline ever since their inception.

I suspect, however, the trend will be different for PCNs.

Currently, there are around 1,250 PCNs, and the “average” PCN is very close to the originally-envisaged upper limit of 50,000.  This means approximately half of the PCNs have population sizes in excess of the 50,000.  Why might that be?  Why have GP practices chosen to group into larger groupings than were expected?

My hypothesis is that the primary reason for this was because PCNs looked like a lot of work right from the outset, and it seemed sensible to group together so that work could be shared out between more practices, and the burden of additional work on anyone practice would be minimised.  The problem is we are now at a point where the resources and funding coming through PCNs is significant, and far outweighs anything that is coming through the core GP contract.  The ARRS in many PCNs will be funding not much shy of a million pounds’ worth of extra roles, and the extended access funding is also likely to be pushing £0.5 million for many PCNs.

What practices want is to feel the benefit of these resources.  The challenge of working with lots of other practices is these resources can feel distant from the practice, there can be lots of different ideas as to how these resources should be deployed, and it can be hard for any individual practice to exert the control it would like to over PCN decisions.

While at first it was helpful for practices to be distant from PCN decision making and to some extent be protected from the additional work, now that the resources are becoming very real many practices are finding the set up frustrating.  Cue conversations between smaller groups of often like-minded practices about what they think should be happening, and wouldn’t it be better if they were their own PCN?

It is a logical step.  Smaller groups of practices in PCNs can have really detailed conversations about how the totality of the resource they now have (existing practice resources and the additional PCN resources) can be combined to deliver maximum benefit to the practices and their patients, and ensure that all of the PCN requirements are met.

The artificial divide between PCN business and practice business does not actually serve either of those businesses, but is necessary when there are multiple practices operating together with relatively low levels of trust.  This barrier is removed when the PCN becomes smaller and the number of practices who have to work together is reduced.

The other factor at play is that it is very difficult to introduce new roles into general practice across large numbers of practices.  Those in the new roles need a home, and to be linked primarily with one practice, and receive all the support that comes with that.  PCN working across multiple practices does not allow that, whereas smaller PCNs can.  We are going to see significant turnover in the new roles next year, and they are likely to settle with those PCNs who are able to look after them.

There it is – more and smaller PCNs next year.  Have a great Christmas, I hope you have a chance to take some well-earned rest, and thank you for all your support this year.

9
dec
0

3 Ways PCNs can make the most of their First Contact Physiotherapist

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One of the most exciting of all the additional roles that are available to Primary Care Networks (PCNs) are First Contact Physiotherapists (FCPs).  This is because they have the potential to take on a significant amount of the general practice workload, and provide some much needed support to GP practices struggling to cope with the sheer volume of demand.  But what do PCNs need to do to ensure FCPs are able to fulfil this potential?

I spoke recently to Larry Koyama from the Chartered Society of Physiotherapy (CSP) on the podcast (you can listen to the full conversation here).  There is lots of great information on the CSP website about FCPs (e.g. here), but out of my conversation with Larry I took 3 key lessons for PCNs to make the most of their FCP:

  1. Ensure the Patient Sees the FCP First

Ok this might sound obvious to some, but there are some places where patients are being referred by the GPs to the FCP.  FCPs are (as described by Health Education England), “Regulated, advanced and autonomous health professionals trained to provide expert MSK assessment, diagnosis and first-line treatment, self-care advice and if required, appropriate onward referral”.  The role of FCPs is not to provide physiotherapy for those patients GPs assess as needing it; rather their role is to provide that initial assessment themselves.

The pathway PCNs need to create is for practice receptionists to be able to book patients directly into FCP appointments.  According to NHS England MSK conditions account for 30% of GP consultations in England, so the potential for workload to be diverted away from GPs via this pathway is huge.

  1. Base the FCP at a Single Site

The default guiding principle for GP practices working together is often equity.  Whatever service or scheme is being put in place GP leaders often have to work hard to ensure it is seen as equitable by all of the practices involved.  What this in turn often translates to when it comes to the PCN additional roles is they are split between all the member practices, so they might be at practice A on a Monday, practice B on a Tuesday, practice C on a Wednesday etc.

The problem with this approach is that, while it may well be equitable for the GP practices and their patients, it makes it very difficult for the new roles to feel they really belong anywhere.  Instead they are treated as visiting clinicians by every practice, and they never feel at home.  And when staff feel they do not belong, they do not end up staying very long.

On top of that, FCPs are new roles into general practice.  It is already difficult for the new starters to try and adapt to the general practice environment.  This sense of overwhelm the new recruits feel is exacerbated when they are have to get used to 5 or 6 different GP practices all at the same time.

A better model for PCNs is to establish a “host” practice for the FCP service, and set up a system whereby each practice can book appointments with the FCP for their patients.  It may be more work for the PCN leaders, it may be less popular with the member practices (less equity), but it will make it as easy as possible for the FCP to feel at home in the PCN, to feel supported, and to make the new way of working as effective as it can be for the practices.

  1. Link the FCP into the wider MSK system

Larry Koyama reported in our conversation that the CSP had looked at all the employment options for FCPs (including individual GP practices and PCNs) and they recommend that existing providers of NHS physiotherapy services employ FCPs.  This means they think that the best employer is actually the local community or acute trust.  The rationale is that it helps to embed and integrate FCPs across the MSK pathway (where they can access training and peer support), and the provider can ensure service consistency and staff continuity.

Now as well as equity, GPs prefer direct control, and I suspect few PCNs are minded to buy in their FCP service from the local trust.  However, what PCNs can do is make sure that professional training and development, as well as mentoring and peer support, is provided by the existing local provider.  This will ensure their FCP is not isolated, as well as linking them in to the wider local MSK system.

 

This year PCNs are only able to employ one FCP this year, but that number will go up next year.  By working hard now to support the FCPs they do have, PCNs will be in a great place to attract more FCPs in future and make the most of all they have to offer.

2
dec
1

What Does the End of CCGs mean for General Practice and PCNs?

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Last week NHS England published a paper in which it backed legislation to abolish Clinical Commissioning Groups (CCGs) by April 2022.  The aim is to replace them by giving the newly developing Integrated Care Systems statutory status.  What will these changes mean for general practice, and in particular for PCNs?

When they were established much of the rhetoric around CCGs was about putting NHS money in the hands of GPs, who know their patient populations and their needs best.  Whilst an attractive idea, the reality right from the outset was close control of CCGs by NHS England with very little room for GPs within CCGs to actively change the flow of NHS money.  Whatever else it might signal, the end of CCGs does not feel like it will be a loss of influence for GPs, because it is not clear that CCGs really ever had any.

NHS England’s paper is significant because it not only heralds the end of CCGs, but also the end of the purchaser provider split in the NHS.  This split was created by the last Thatcher government in the early 1990s in an attempt to create an internal market within the NHS.  Hospitals became provider Trusts, money to purchase care was given to Health Authorities, and GP fundholding was the first iteration of GPs being involved as the “commissioners” of healthcare.

What this paper does is (in effect) recommend the split (which has been largely ignored since the publication of the 5 Year Forward View anyway) is finally put out of its misery.  It is fair to say it was an experiment that has not worked.  At 30 years it is probably also fair to say it was an experiment that was allowed to go on for far too long.

What does this mean for general practice and PCNs?  Integrated care systems (ICSs) are to become statutory bodies, and general practice is represented on ICSs by PCNs.  Indeed, PCNs were created to represent local populations of 30-50,000 within ICSs, and ensure care is organised across agencies around the needs of those local populations.  It means the role of PCNs will become even more important.

Where in the internal market the commissioning organisation was expected to exert control over the delivery of local care via the use of contracts with provider organisations, within the new system the provider organisations are expected to work together and make sensible decisions as to how to use their resources to improve outcomes.

I can almost feel your scepticism as you read these words as to whether the new system will make things any better.  What the internal market has done through its attempt to create internal competition within the NHS is not to improve efficiency (as intended) but instead breed huge mistrust between different provider organisations.  It is going to take time for these organisations to get used to the new environment and learn to trust each other.

The real opportunity for the new integrated care system to work is only (in the short to medium term at least) at a local level.  Where relationships are between individuals trust can develop and mature quickly.  Where relationships are between organisations, with years of bad blood to overcome, trust will take much longer to build.  Front line clinical teams talking to front line clinical teams and working out sensible ways of doing things is how integrated care can make a difference that the internal market never could.

The changes that are coming represent an opportunity for general practice and PCNs, but they will need to take action to ensure they can make the most of it.  By April 2022 PCNs will be nearly 3 years old, and by then they need to be firmly established, have built some delivery capacity and capability, and have developed strong working relationships with local partners.  The challenge for PCNs and GP leaders in the meantime is to ensure that as ICSs develop primacy is given to making and supporting change at a local level, and that decision making doesn’t drift into large regional areas divorced from local teams.

25
nov
1

Working Together: Covid-19 Vaccinations

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It has been a stressful few weeks for many practices.  Not only did practices find out via the BBC that flu vaccinations for the over 50s are to commence from December 1st, they also had to agree with their neighbouring practices which sites are to be used for the delivery of the Covid-19 vaccine.

Working together is not easy.  Trust is hard to build between practices, and despite the progress made in recent months, agreeing a single site for Covid-19 vaccinations across PCNs within a week was always going to be challenge.

At the root of this challenge is the money at stake.  If the average practice has 8,000 patients, and we conservatively estimate that only half of these will receive the vaccine, then that is 4,000 patients x2 shots each x £12.58 a shot.  Which equals over a £100,000 per practice.  That kind of money will always create tension, but especially in a year like this when practices are under so much financial pressure.

Most practices would have preferred to deliver the Covid-19 vaccine in the same way that they deliver the flu vaccine to their patients – in their own practices with their own staff.  But the nature of this vaccine (it arrives in batches of 975, has a shelf life of only 5 days, is difficult to transport and wastage is not an option) means that it simply is not possible at this point in time.

The logistics are not the only reason it makes sense for practices to work together to deliver this vaccine.  Practices already have to deliver the flu vaccine to a huge new cohort at the same time as the Covid-19 vaccine becomes available.  The ask of practices already during this second peak of the pandemic is to manage the new virus on top of everything else that practices have to do.  At the same time as winter properly kicks in.  Individual practices simply do not have the spare capacity.

While the workload is growing, the workforce is much less resilient.  Everyday different practices are faced with the challenge of huge swathes of staff either sick or needing to isolate.  Individual practices cannot be sure they will be able to keep normal services running, let alone an additional vaccination service that requires 975 injections within a 5 day period.

Delivering this vaccine also requires a level of management capacity not present in the vast majority of individual practices.  We know the logistics are extremely challenging (think enabling national and local booking, cold chains, training staff, organising volunteers, working with other agencies on communication messages, managing the IT, without even getting into the reporting requirements that will inevitably be necessary).   It is not realistic to think a practice manager can do all this in their spare time.

The financial efficiencies are potentially greater working together.  A well run single site operating with a clear set of processes and flows can minimise the costs by maximising the numbers running receiving the vaccination each hour, and by working effectively with volunteers and partner agencies.

Many practices dislike working together, because it is difficult and requires a ceding of control.  But if there was ever a set of circumstances where it makes sense for practices to work together this is it.  That does not make it easy to achieve, or change the local politics or difficult relationships, but nonetheless it is an opportunity.

The vaccination programme has huge societal implications, and is a massive opportunity for general practice to be a key part of taking this country out of the situation it is currently in, but my one piece of advice to those trying to make this joint working happen is not to ignore the money.  Whether it is what is being talked about or not by practices, it is an issue that needs to be explicitly addressed.  Be clear how will the money flow, how it will be transparent, and how it will be fair.  It might not be the most important, but it is certainly an essential step to making the joint delivery of the Covid-19 vaccine by general practice a success.

18
nov
0

Making a Difference

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It has been a difficult year.  Coping with Covid-19, and all the challenges that it has brought both personally and professionally has been difficult for everyone.  The first lockdown was hard, but the second lockdown in many ways feels harder, because we understand the scale of the challenge and what will be required to get through it.

This time round some of the fear from the first lockdown has gone, because we know what to expect.  But instead it has been replaced with a tiredness.  Without really having the time or opportunity to recover from the first time round we are having to do it all over again.

For general practice lockdown 1 and lockdown 2 feel significantly different.  When lockdown 1 happened the message was to stop everything to make sure that patients with coronavirus were looked after.  In lockdown 2 the message seems to be that general practice should be open for business as usual, and be absorbing the covid challenges on top of everything else.

Now the ask is for general practice to also take on the covid vaccination programme.

It easy to react from a position of tiredness.  How can we find the energy to take on all the logistical and operational challenges this brings, on top of everything else?  Especially when it feels like we are already running on empty?  I know I personally am guilty of reacting like this.

But the reason I (like many of you) chose healthcare as the industry that I wanted to work in, as opposed to investment banking or commercial law or anything else, was because I wanted to make a difference.  I wanted to not just earn a living, but to do so in way that a made a positive difference to others.

Playing a part in the covid vaccination programme is likely to be my opportunity to make the biggest difference maybe I will ever be able to make.  A vaccine is the only route by which we can re-gain our lives, our economy, our normality.  Without it, as we have seen, the pandemic takes over everything.

So yes it is hard, and it is difficult to summon up the energy and personal resources, but really it is a huge opportunity.  Undoubtedly general practice will rise to the challenge, and play a leading role in taking the country out of the crisis it finds itself in.  I want to be part of it.  I want to know that when it mattered most, I made a difference.

11
nov
0

Time for a PCN Stocktake: 10 points to review

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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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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?

 

  1. 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.

 

  1. 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.

 

  1. 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?

 

  1. 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.

 

  1. 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.
4
nov
0

The PCN Retention Challenge

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After a slow start last year, when PCNs displayed considerable reticence about taking up the additional role reimbursement scheme (ARRS), things have taken off this year.  There is a recruitment frenzy underway, with thousands of new roles being recruited across the country.  But could all this recruitment energy be being expended in vain?

The biggest challenge PCNs face is not recruiting to the roles in the first place (although one colleague described it to me as being like the “wild west” out there, as some PCNs do whatever is necessary to secure candidates – regardless of whether they have already accepted an offer elsewhere).  The biggest challenge will be keeping the ones they do manage to recruit.

For a start, PCNs are not actually organisations.  They are collections of practices, so when an occupational therapist or care coordinator is recruited by the PCN it is not 100% clear exactly who they are working for.  It is this sense of the new staff not belonging that is difficult for PCNs to overcome.

There are already plenty of stories of new staff arriving on their first day who discover they do not have a base (“could you work from home for now…”), a clinical space to operate out of, or any sort of induction.  It is not going to be long before those particular new recruits start looking elsewhere.

Even for those PCNs that have managed to put the basics in place, there is still the challenge for any new starter of working across multiple practices.  Each practice has its own systems, processes and way of doing things.  Will every practice make the new starter feel equally welcome?  Unlikely.  More likely is that very quickly they will start to dread Wednesdays and Thursdays when they have to go to practice X and practice Y.

Introducing new roles into general practice has never been easy.  It is not clear to many GPs and many GP practices exactly what value the new roles can bring to them.  The challenge pre-PCNs of introducing new roles was not a lack of availability of the staff, but a lack of belief amongst practices that they could make a significant difference to the workload.  This has not changed just because PCNs are providing the funding.

“What does the dietitian/physician associate/health coach (etc, delete as appropriate) actually do?” and “can’t we just use the money for an extra GP instead?” are not uncommon questions in practice meetings discussing the new starters.  And it is into this environment that PCNs send the new recruits, often without any real warning of what to expect or any support in overcoming known areas of resistance.

Even when all the practices understand the role, know how it is supposed to function, and are fully briefed and prepared for it to begin, it is still challenging for any individual to feel like they belong anywhere, when everyday they are in a different practice working with different people, and always feeling like an outsider.  When hostility is palpable in half of those practices, the experience goes from feeling like an outsider to more like an unwanted intruder.

Clearly the new roles will work better when they are in, and feel part of, a team.  But what should the team be?  Should they have a ‘host’ practice, and become part of that team? Or should they be part of the team of all the new roles working across the PCN?  Or should it be by professional group – so all the pharmacists form one team, maybe across multiple PCNs?  Or should it be a PCN project team working on something across the PCN, which includes members of existing practice staff as well as the new roles?  Or something else?

I am not sure it matters what the team is, but for the (lack of) ownership issue to be overcome I am sure it is vital that the new roles are part of a team, with a leader, clear objectives, and identified support.

I know some places have done this, and where they have many already have a waiting list of applicants disillusioned with their new life elsewhere who are keen to join.  Recruitment may have been very challenging over the last few months, but it will all have been for nothing if that effort is not at least matched with an equal effort to look after these new staff.  High turnover rates in these new roles is extremely likely in the coming months, and the winners will not be those that pay the most but those that provide the best support.

28
oct
0

Do PCN finances stack up?

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I understand the primary aim of PCNs is not to be a source of income for practices, but it is important they don’t become a drain on already under pressure practice finances.  So do PCN finances stack up?

Just as a reminder, the aim of PCNs (according to the BMA) is to focus services around local communities, help rebuild and reconnect the primary healthcare team across the area, alleviate workload, be practice-led, and allow GPs and primary care practitioners to deliver a new model of care for their patients and communities.  It is interesting there is no mention of money, despite the financial challenge in general practice PCNs are supposed to be part of the solution to.

The headline investment figure into PCNs is the Additional Role Reimbursement Scheme (ARRS), which brings with it total investment of £1,412M by 2023/24, equating to an average reimbursement pot of £1.13M per PCN.  Member practices receive a £1.76 participation payment.  PCNs directly receive £1.50 core funding (which I discussed last week), 2 to 3 sessions reimbursement for a Clinical Director, and the Investment and Impact Fund – the proceeds of which PCNs have to commit to reinvesting in additional workforce or primary medical services.  There are also extended hours payments and care home “premium” payments, but these are funds for specific pieces of additional work.

The eye catching figure is of course the investment via the ARRS.  But what is increasingly emerging are a set of hidden (and not so hidden!) costs for PCNs and their practices associated with these roles.

Many areas have not been able to recruit the roles within the salary reimbursement available, and each role where this has been the case becomes a cost pressure on the PCN.  These cost pressures will accumulate as more roles are added, and as staff expect pay rises beyond the reimbursable amounts available.

It is also unlikely the on costs will meet the training, supervision and professional development costs of the roles, along with equipment and property costs – apparently NHS Property Services has recently stated that where its property is used to house PCN services this will incur additional property costs for those practices.

When PCNs were first being set up there was quite a bit of talk about the risk of incurring VAT, but that died down relatively quickly.  However, as PCN turnover starts to exceed the VAT allowance of £85,000, which it increasingly will do as the number of roles recruited to increases, then the spectre of this charge will quickly re-emerge.  There is no obvious source of funding to meet any such VAT charge, other than directly from member practices.

The other issue for PCNs to consider is whether they should be creating a financial buffer, to mitigate the potential risk of any employment costs that may arise out of the new PCN staff group.  Often companies will try and ensure they have at least three months of salaries as a financial buffer, which by 23/24 would be £250-300K for an average PCN.  That money will need to come from somewhere.

What approach, then, should PCNs take to PCN finances?  It seems to me that PCNs have one of two choices.

They could choose to think about PCN finances in terms of the net impact on member practice finances.  This would mean practices actively monitor the total positive impact on practice profitability of the PCN.  They would take the £1.76, the impact of the new roles in reducing staff costs, and any increase in income from PCN contracts, and subtract any direct costs to the practice of the PCN, such as financial contributions, property charges and staff time, and ensure that it remains net positive.

The key to making this approach work would be ensuring each practice receives a direct positive impact from the additional roles that are brought in, rather than treating them as PCN-staff that are not really anything to do with the work of the practice.

The other option would be for PCNs to operate financially like a business.  The principle here would have to be that the total income of the PCN should match the total costs.  Outside of the DES contract itself there are soft funding pots available, both through the national PCN development funds and local initiatives.  The Investment and Impact Fund was initially presented as an opportunity for PCNs to earn money by reducing secondary care expenditure, but that was lost as it was watered down into what we have now.  The big potential income generating opportunity on the horizon is the shift of extended access funding to PCNs from next year.  It remains to be seen whether this too will still exist once the final guidance has been agreed.

My worry is that many PCNs at this point in time are not taking either of these approaches.  PCN finances can stack up, but to do so will require active financial management.  The big risk is that without this in place PCNs could end up having a significant negative impact on member practice finances.

21
oct
0

The £1.50 Challenge

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Each PCN receives “core funding” of £1.50 per patient.  The Network DES states, “A PCN is entitled to a payment of Core PCN Funding for use by the PCN as it sees fit” (9.5.1).  This freedom has created a level of ambiguity around the use of this funding that is hindering rather than helping most PCNs.

If we start at the beginning, there is no way that £1.50 per patient (c£75k for the average PCN) is sufficient to cover the running costs of a PCN.  A PCN will soon be employing upwards of 20 staff, and be managing a budget well in excess of a £million.  It is not possible for the administrative overhead to be £75k and expect payments to staff and practices to be made accurately and on time, for staffing issues to be dealt with appropriately, and for the huge system expectations of PCNs to be met.

A helpful piece of context might be the running costs of CCGs.  When they were established they were allocated £25 per patient (which was still a cut on the running costs of their predecessor PCTs).  Admittedly PCNs are not statutory organisations like CCGs, but the expectations are still high, and having only 6% of the running costs given to CCGs highlights the challenge PCNs are facing.

PCNs may have been able to get by so far, as the actual demands have been limited to sorting out extended hours and some early recruitment.  But now there are new staff in post, 3 service specifications to deliver, and with the prospect of sorting out extended access on the horizon things are soon going to feel very stretched.

The challenge many PCN Clinical Directors (CDs) are facing is their member practices do not want the £1.50 to be spent, and resist proposed uses of the fund.  Because the expectations were relatively light in year one some PCNs were able to return some (or even all) of the £1.50 to member practices.  This in turn has set an expectation that practices will receive some such funding directly from the PCN each year.

So when a new PCN manager is under pressure it can often turn into questions to the CD from practices about what value are we really getting from this role anyway?  And before you know it, the PCN has decided they do not need a PCN manager after all.

Other PCNs have turned to the £1.50 to make up for the shortfall in the ARRS funding for the new roles.  So where the roles have come with additional costs (salary shortfalls, training supplements, venue/location costs etc) the £1.50 has been used to meet the deficit.

The problem of course is that this will only work for the first couple of roles.  If you are cutting £75k across more than 20 roles it is not going to solve the overall funding shortfall problem that the ARRS scheme presents.  At the same time, it is eating into an already underfunded running cost allocation.

I have written previously on how essential the PCN manager role is.  There is a rumour that PCN managers may be included in the next list of roles that can be funded from the ARRS.  But whether it is or isn’t, no individual can be an expert change manager, project manager, finance manager and HR manager.  PCNs need a team of support to be successful.

The £1.50 challenge for PCNs, and particularly for PCN CDs, is how to withstand pressure from member practices not to spend it or to spend it on topping up additional roles, and instead to use every penny to put in place the best possible support infrastructure for the PCN.  Because without it, the PCN is going to struggle as it moves forward.

14
oct
0

Is the PCN CD Model Reinforcing Historic Leadership Approaches and Cultures?

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Introduction

In 1998 I completed an MBA. For my dissertation I undertook a triangulated study to identify the barriers to public participation in General Practice. I found culture, leadership and structure of General Practice to be contributory factors.  These terms were alien to NHS management language at the time. In the emergent purchaser provider split of the time, with the introduction of commissioning and competition into the NHS, there was a reliance on quantitative and empirical evidence, with little room for qualitative evidence. As a result, my dissertation sat on a shelf until I became a Practice Manager.

Finding my personal motivation and beliefs constantly conflicted in a toxic command and control environment, I found it increasingly challenging to function as a middle manager in commissioning. At the time, I thought academic leaning was my route to influence in the NHS. Heading towards a PHD I was head hunted to apply for a practice manager job. Taking it became the best decision of my career. More on that later………………

Fast forward to November 2019 when I was fortunate to attend a Kings Fund conference on “The Challenge of Culture Change in the NHS”.  Promoting a move away from the command and control culture, this event explored the type of culture (in alignment with the Interim NHS People Plan) that would make the NHS a better place to work in. The emergent words on the day included “collaborative and compassionate culture and leadership”. This brought music to my ears. Emotionally exhausted from hearing some very brave individual accounts of collaborative and compassionate leadership, I left the conference with renewed hope and personal ambition!! I had waited two decades for this.

Having dusted off my MBA dissertation and reflected on my findings, it becomes clear to me that the structure, culture and leadership style in individual practices not only prevented meaningful engagement with patients and the public, but may also be a contributing factor to the challenges we face in embedding PCNs and new models of care.

Leadership and Culture

Many GP practices aspire to a command and control leadership style and culture, aligned to a vertical organisational structure. This leadership style is authoritative in nature and decision making is top-down. Privilege and power are vested in the Senior Partner (the heroic leader) with limited opportunities for broader involvement and engagement. This leadership style facilitates a weak organisational culture, one in which core values are not defined or communicated. The absence of shared values results in individualistic compliant behaviour, with a greater need for policies, procedures and bureaucracy.  Employees are compliant with low morale. Staff are disengaged and disempowered.

 

A weak culture is associated with:

  • Incompatible vision, mission, goals, and a lack of understanding about the future direction of the organisation, which may lead to failure;
  • Lack of leadership, poor direction from senior managers, competition and poor role models, and;
  • Lack of quality of service provision, poor running of the organisation, and priorities externally perceived as being incorrect.

 

A strong positive culture is evident in practices where members within the organisation have deeply embedded shared values and beliefs. In this culture committed employees understand what is required of them and are empowered to act in accordance with the core values. Bureaucracy is reduced and there is high staff morale, engagement, and productivity. Internally, this positive culture provides the “glue” that binds the organisation together. Many practices with this culture and collaborative, compassionate leadership style are forging the way forward towards successful new models of care and scaled up General Practice.

 

The Practice Manager Continued….

Working at Oxford Terrace Medical Group taught me that command and control is not the only model available to general practice. There was no Senior Partner.  Leadership roles were distributed across the partnership.  Individual partners worked with the practice manager on management issues, taking an active role in running their business. At first there was limited involvement of patients and the broader Primary Health Care Team.

 

Equipped with my MBA and the necessary operational management skills, my first job was to co-ordinate a merger with a failing practice. It became very clear to me early in the process, that operational management skills alone, were not adequate for the culture change required to lead large scale transformational change. With three clear strategic priorities: improving access; transforming the workforce, and premises development, I embarked on a quality improvement programme. This provided structure for the merger project, through three modules:

  • Fundaments of quality improvement;
  • Human dimensions of change, and;
  • Facilitation Skills and developing a compelling narrative.

 

A focus on human dimensions of change and quality rather than finance, transformed engagement of patients and employees during, and after the merger, enabling us to achieve the first two priorities quickly. We developed new roles (Frailty Nurse, Older Peoples Specialist Nurse, Care Navigator and Occupational Therapy in GP) to meet population need, this helped us to manage the access issues. Tied up in the merry-go-round of the ETTF process, premises development eludes me to this day.

 

What I learned was that a distributed leadership model focused on engagement and collaboration could not only succeed but also make a real difference within the general practice environment.

 

Quality Assurance and Quality Improvement

CQC further perpetuates the command and control leadership style and culture through target driven “quality assurance”, stifling opportunities for collaboration and the value of quality improvement. The Well Led KLOE, focused on transactional process is a clear indication of this.

 

There is a recognition now that the Well Led KLOE is limited, and there are plans to split the transactional (quality assurance) from the transformational (quality improvement) elements. A strong organisational culture requiring less bureaucracy, is better placed to facilitate quality improvement and collaborative, compassionate leadership with strong organisational culture.

 

Putting quality at the heart of the organisation, embedded though continuous improvement, involving all levels of the organisation working together to produce better services and care, through transformational processes and action. Quality improvement relies on the use of methods and tools to continuously improve quality of care and outcomes for patients. There is no place for command and control leadership in this environment.

 

PCN Leadership and Culture

Faced with changing demographics, people living longer with long-term conditions, with increasingly complex health needs alongside a shortage of GPs and nursing staff, the unprecedented pressures in primary care are well rehearsed. To date, workforce in general practice has remained simple with GPs, Practices Nurses, Health Care Assistants, Administrative staff and recent introduction of pharmacists in some practices. As new roles emerge, a different leadership style, culture and structure will become essential to enable safe embedding and sustainability of the new roles.

 

It is disappointing then, that the traditional leadership style and culture has been lifted and shifted from General Practice into Primary Care Networks in the guise of the Clinical Director role (The heroic leader).  Lip service is paid to management and non-clinical leadership, with only one paragraph in the PCN DES relating to administration support for CDs. The ensuing effects are already being felt by individuals and across the system.

 

Contracting of PCNs perpetuates financial incentives to passive engagement. This culture, with a focus on process, individual targets and transactional approaches to organisational and team development minimises the full potential of PCNs.  It limits the opportunities of active participation of individual practices. This will result in increasing performance management and bureaucracy for practices to maximise PCN income.

 

The rhetoric is around collaboration and integration, but actions are individualistic. The structure around practices is changing, but there are no incentives in the contract to influence and facilitate the necessary culture and leadership changes for collaboration and integration. The continuation of the existing culture, leadership style and levels of engagement across PCN practices will present significant risk to the introduction of new roles working across practices. Patient and staff safety will, therefore, be compromised.

 

To grow and flourish, PCNs will require a different leadership style and culture. A collaborative and compassionate leadership style, embedded in a strong positive, supportive and facilitative organisational culture. For PCNs to succeed we need Clinical Directors functioning as inspirational leaders, supported by a collaborative infrastructure with complementary skills.

 

Conclusion

My conclusions in 1998 were that the structure, culture and leadership style of general practice were barriers to patient and public involvement. My reflection now is that these are also contributing factors to some of the challenges we face in general practice, potentially including the move away from partnerships.

In his last address to the North East RCGP faculty: GP Reimagined conference in 2018: the late Sir Donald Irving (RIP) invited us to be brave, be accountable and be responsible in order to maximise the benefits and opportunities offered by new models of care. I believe, this is exactly what we must do to transform not only the structure of general practice, but also the leadership style and culture. It will take a brave leader to challenge the engrained culture that has endured decades of change in General Practice but maybe the time is nigh!

7
oct
1

10 Challenges PCNs face introducing new roles

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The majority of PCNs are experiencing difficulties as they recruit into these new roles.  Here are 10 challenges PCNs are grappling with:

  1. Understanding the Role

Just because a PCN has recruited a social prescribing link worker (for example), it does not mean the practices in the PCN understand what the social prescribing link worker should be doing, or that the new incumbent understands what they are to do in the new PCN environment.  There are a growing number of examples where this basic lack of clarity on both sides is leading to the early breakdown of new roles.

  1. Recruitment Capacity

Many PCNs are recruiting as many as 10 new roles all at once.  This involves creating job descriptions, developing different job adverts, shortlisting from maybe 100 applications, interviewing up to 50 applicants, negotiating 10 job offers, creating 10 contracts and putting in place 10 induction plans.  It is a huge amount of work for any PCN, and many PCN CDs are finding the scale of the required work simply overwhelming.

  1. Line management

There is a huge challenge introducing a new role into a practice, let alone a PCN.  The change process involved creates tensions within the practices in the PCN and inevitably for the new role incumbent.  These individuals require line management support, in addition to making sure their equipment, annual and sick leave is being managed.  Many PCNs initially underestimated the line management requirements of the new roles and are finding it difficult to create the additional capacity needed to support the new recruits.

  1. Location

General practice is not sitting on lots of empty space, and a huge challenge for PCNs as the new roles start is finding the clinic space for them to operate out of, as well as identifying desk space for their permanent base.  There is no obvious remuneration for this (there are only so many times you can spend £1.50), and so unsurprisingly it is creating internal disputes between PCN practices.

  1. Clinical Supervision

The new recruits come with varying levels of experience.  In particular the physician associates currently being recruited are often still to sit their final exams, let alone have any years of professional experience.  The clinical supervision requirements, particularly when these new roles first start, are significant, and PCNs are often relying on the goodwill of individual GPs from across their member practices to ensure these are met.

  1. Professional Development

Each of the new roles requires support and a plan for their continuing professional development.  There are pathways laid out for some of the roles, for example for the clinical pharmacists, which again require significant input from the PCN.  Health Education England is providing some resource to training hubs to support this, but in many areas this is not converting into the tailored, individualised support that PCNs require.

  1. Ownership

Who exactly do the new recruits into PCNs work for?  PCNs are not legal entities, and while they may comprise of the member practices, practices in general see the PCN (and so the new recruits) as separate to themselves.  New recruits often arrive but end up not really being owned by anyone, as they work for a PCN that no one really owns.  If a new recruit does not feel they belong anywhere, or that anyone really wants them, it will only be a matter of time before they start looking elsewhere.

  1. Additional Costs

The ARRS funding formula is rigid in terms of what PCNs can claim for.  Each additional role generates its own set of additional costs.  In some of the bigger urban areas this even includes salary costs, before we even get into some of the unfunded delivery costs.  Normally a business generates income to enable these costs to be met, but the nature of the PCN contract means there are very few ways PCNs can generate additional income (the potential impact of the Investment and Impact fund looks limited).  Given these costs it is hardly surprising that enthusiasm for additional roles from PCN member practices is often somewhat muted.

  1. Monitoring Impact

One of the key ways any new role establishes itself in a new environment is by demonstrating the value it is adding.  While there are some examples of some of the new roles starting to do this, e.g. first contact physiotherapists demonstrating a reduction in the number of GP appointments and secondary care referrals, for many of the roles there are no clear impact measures in place.  However they are funded, practices need to see the value the new roles are adding.  Otherwise it will be only a matter of time before discontent with the additional time and cost burden of the new roles reaches unsustainable levels.

  1. Retention

It is unsurprising given all of these challenges that even where PCNs have been able to recruit the new starters often do not stay for very long.  In part this is due to the huge number of additional roles being recruited by PCNs up and down the country and the seller’s market this is generating, but primarily it is because PCNs haven’t had the time, capacity or support to work through many of the challenges above.  The result is many new recruits are moving on quickly.

 

It is when you think about the extent of these challenges that the assessment of some GP leaders I have spoken to that we are still 12-18 months away from feeling the impact of these new roles starts to make sense.  It is going to take that long for PCNs to establish the systems, processes and ways of working that will enable these new roles to thrive and flourish.  In the meantime what PCNs need is support and assistance to help them get there as quickly as possible.

23
sep
0

The PCN Investment and Impact Fund Explained

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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 1st and March 31st 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:

Indicator No of points Upper limit Lower Limit £ available
% patients aged 65+ who received a seasonal flu vaccination 72 77% 70% £7,992
%patients on the learning disability register aged 14+ who received an annual learning disability health check 47 80% 49% £5,217
% patients referred to social prescribing 25 0.4% 0.8% £2,775
% patients aged 65+ currently prescribed a non-steroidal anti-inflammatory drug (NSAID) without a gastro-protective medicine 32 30% 43% £3,552
% patients aged 18+ currently prescribed an oral anticoagulant (warfarin or a direct oral anticoagulant) and an antiplatelet without a gastro-protective medicine 6 25% 40% £666
% patients aged 18+ currently prescribed aspirin and another antiplatelet without a gastro-protective medicine 12 25% 42% £1,332

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.

16
sep
0

The Growing Influence of PCNs

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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.

9
sep
1

Do PCNs need a manager?

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In the update to this year’s GP contract the increase in funding for additional roles for PCNs from 70% to 100% was heralded in this way:

“We have heard that the £1.50/head support for PCNs – worth £72,000 annually for an average PCN – has been deployed to contribute to the 30% funding of additional roles.  Instead it can now be used as needed for development and transformation support.  It equates to a full-time band 8A, and increasing the contribution of Clinical Director time by almost 50%.  We encourage Clinical Directors to use the funding to ensure sufficient support as rapidly as possible”.

A band 8A manager, for those not fully conversant with NHS pay scales, attracts a not insignificant salary of between £45,753 and £51,668.

Some PCNs have taken the plunge and employed a manager.  Others are more reticent.  The relative ease with which the PCN requirements were able to be handled in 2019/20 meant many PCNs decided to return much of the (unused) £1.50 to practices at the end of the year, and in doing so set a precedent that some PCN CDs are now uncomfortable breaking.

Part of the problem of course is that a salary of c£50K for a PCN manager is significantly higher than the salary of the average practice manager.  On the one hand, PCN CDs don’t want to be accused of stealing practice managers from local practices, and on the other it is very hard for a manager with no local knowledge to come in and work effectively across practices.  Especially when the local PMs know exactly how much the incoming PCN manager is being paid…

It is very difficult for an outsider to come in as manager and be effective straight away with a group of practices.  This requires trust, which needs time to build, and the covid restrictions make that all the more difficult right now.  It is hard to build relationships via Zoom.

Do PCNs really need a manager?  Is it worth the investment?

Many PCNs have been able to cope perfectly adequately without one until now.  Unfortunately this is no great indicator that this will be the case in future.  On October 1st three new service specifications kick in for PCNs (care homes, medication reviews and supporting early cancer diagnosis), alongside the requirement for PCNs to offer a social prescribing service.  In addition, the new Investment and Impact fund (think PCN QOF) begins.

In six months’ time four more service specifications will need to be delivered, while at the same time PCNs will take on the responsibility for delivering extended access.

Many PCNs are currently recruiting an average of 10 staff, with another 6 or 7 to be recruited by the start of next year.  These staff will generate work, headaches and challenges (new staff always do), and someone will need to pick up the pieces.

Without a PCN manager, who is going to do all of this work?  This is without mentioning the plethora of system meetings (just say no), the data sharing and patient engagement requirements, and any local initiatives the PCN has committed to.  Is the PCN CD expected to do all of this in 2 or 3 sessions a week?  Or the PCN practice managers in their spare time?  I don’t think so.

If your PCN does not yet have a manager in place, the time has come to bite the bullet and recruit.  From October not having a PCN manager will cost more than having one.  Don’t put it off any longer.  Some practices might not like it, but the sheer scale of work means that PCNs will not be able to function effectively without one from October.

2
sep
0

Why Flu Planning is So Difficult this Year

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There cant be anyone working in general practice who has not yet been asked what their plans are for the flu season.  But I am not 100% sure those asking always understand why the question is so difficult this year.

We are still very much in the planning stage, as we await the arrival of the first vaccines.  It is difficult to know how well prepared practices are, but what is certain is preparations are much more difficult than in previous years.

In part this is because of national shifting sands on three fronts: the cohorts to be vaccinated; the PPE requirements; and getting hold of the vaccines.

The season started with a message that 50-64 year olds are to receive the flu vaccine this year.  This was then changed to a message that this will only happen later in the season, if vaccine supplies allow.  So now we have a vocal cohort of individuals contacting practices demanding a vaccine that practices won’t be paid to administer, and confusion across practices as to exactly what they are supposed to be doing.

Initially the PPE requirements were a face mask for every session, with new gloves and apron to be worn for each patient.  Once forward thinking practices, PCNs and GP federations had dutifully mass purchased the required equipment, the guidance was changed so that only sessional face masks are now required.  And who knows whether it will change again in future.

As for vaccine supplies, no one knows how that is supposed to work.  Because practices generally order vaccines a year in advance, the orders placed are for the normally expected amounts.  This would be 50-55% of a practice’s usual cohort, which means practices are well short of the 75% needed to achieve the target, even before this year’s additional cohorts are added on.

Anyone who has tried to order additional supplies will know all remaining vaccine stocks are being purchased centrally.  What we don’t know is how any central supply will work in practice, and how these vaccines will be distributed to practices.  But given the recent experience of central purchasing and distribution of PPE, it is not surprising there is little confidence amongst practices that this will work well.

However, these are not even the biggest challenges practices face in developing their flu plans.  Traditional systems of flu delivery (bringing in large numbers of patients over a weekend or two) simply will not work this year.

The social distancing requirements mean that patients need to be given more specific appointment times, and the usual method of “stacking” multiple patients at once cannot be used.  The high DNA rates that can usually be offset using this method will have a significant impact.  Practices will also need additional staff to ensure social distancing standards are adhered to and manage any queues that form.

At the same time, the social distancing and PPE requirements mean that clinicians will be able to vaccinate far less patients per session.  I have seen the overall impact of this estimated at a vaccination rate of one patient every six or even eight minutes, compared to one roughly every two minutes in previous years.

What this means is that practices can see less patients in a session, but with higher staff costs.  The net impact has been estimated as meaning that the costs of vaccination will rise by between £6 and £9 per patient.  This of course calls into question whether practices can even carry out the vaccinations this year for the fee that is being offered (which currently remains unchanged from previous years).

This is why flu planning is so difficult this year.  I am not sure the system fully yet understands the extent of the challenge this creates for general practice, but I suspect when we move from the planning to the delivery phase these challenges will become much more evident.

26
aug
0

Start Recruiting 2021/22 Additional Roles Now

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We have all been struggling to get our heads around the Additional Role Reimbursement Scheme (ARRS) for PCNs, and in particular how to make most of the opportunity it creates.

Significant changes were made to the ARRS in the 2020/21 GP contract (in particular the increase in reimbursement from 70% to 100%, and widening the number of available roles to 10).  However, the impact of these changes were somewhat lost initially, as a result of uncertainty as to whether PCNs were going to sign up to the revised DES and, of course, the emergence of coronavirus.

But now PCNs are moving forward as quickly as they can with their recruitment plans.

The problem is, despite an apparent enthusiasm nationally for each PCN to use all of its ARRS fund to be used, the rules seem to conspire against this happening.  PCNs can only be reimbursed up to a maximum monthly reimbursable amount, which means funds can only be used once the new staff are actually in post.

In order to spend all of the money PCNs would have needed their new staff to be in post on the 1st April.  But given at that point most practices had not even signed up to the DES, not to mention the distractions posed by the small matter of a pandemic, it is not surprising that for many PCNs staff are only being recruited now.

It seems likely (and entirely reasonable, given the PCN DES specifications only start on the 1st October) that the majority of the new PCN roles will probably not be in post until October.  And if the PCN staff do not start until October this means somewhere in the region of half the available ARRS money will not be spent.

How then can PCNs ensure they make the most of the available ARRS fund for this year?

The best way is for PCNs to start their recruitment to their 2021/22 roles now.  PCNs can use the underspend against this year’s roles to pay for additional months of next year’s roles.

The “average” PCN has £344k available for additional roles this year.  This goes up by nearly 75% to £597k next year.  Even a PCN that is on track to spend as much as 70% of its funds this year could still afford to have all of its roles for next year start in the middle of November this year, and remain within budget this year and next.

This means, taking into account the need for notice periods and the delays these cause to recruitment, PCNs who want to maximise the use of their allocation would be wise to start their recruitment for next year now.

One caveat of course is that paramedics and mental health practitioners cannot be employed until April 2021.  These roles will be popular, so even for these it is worth considering starting the recruitment process at the end of October/early November so that they are recruited and ready to go on April 1st 2021.

Even for those PCNs who did manage to get ahead of the curve and are not looking at much of an in year underspend, it is still worth being ready for early recruitment to next year’s roles.  It is highly likely your neighbouring PCNs will have an underspend (because the majority will), and the rules are that any underspend in an area should be offered in the first instance to the neighbouring PCNs, rather than being lost to general practice.

PCN recruitment may have got off to a slow start this year, but I suspect this wont be the same in the years to come as savvy PCNs get started well before the next year begins!

19
aug
0

How to Create Effective Representation for your PCN

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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.

12
aug
0

Who can Represent my PCN?

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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.

5
aug
0

Why attending less meetings will increase the influence of your PCN

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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.

29
jul
0

Should PCNs Choose the Greater Good?

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“There are plenty of teams in every sport that have great players and never win titles. Most of the time, those players aren’t willing to sacrifice for the greater good of the team. The funny thing is, in the end, their unwillingness to sacrifice only makes individual goals more difficult to achieve. One thing I believe to the fullest is that if you think and achieve as a team, the individual accolades will take care of themselves.”  Michael Jordan

 

There is an interesting dilemma facing many practices right now, as they work out how to make the most out of PCNs.  Is it better to maximise the gains for your own individual PCN, or is it better to work together with other PCNs to maximise the gains for general practice as whole?

This manifests itself when a collection of PCNs in an area have to make a decision, and different PCNs have different views.  The decision could be for example whether one individual can represent all of the PCNs in a system-wide meeting.  If that individual can speak as a united voice on behalf of all practices then the overall voice of local practices is stronger.

But that individual may not fully represent the views of “our” PCN.  What if we don’t fully agree with what they say, or don’t trust them to put our point across?  We end up feeling the need to represent ourselves and our own PCN.  But now there are two voices of local general practice.  And if we contradict each other, the overall voice and impact of general practice is diminished.  But at least we know that our individual view and has been represented, and our views fed accurately into the system-wide discussion.

Or maybe we need to decide whether our PCN should use the federation to deliver extended access services, or whether we deliver these directly as a PCN.  If all the PCNs agree to the same model, the overall costs and administration to general practice are likely to be cheaper.

However, an individual PCN may be able to develop its own model which delivers greater retained profits for its member practices.  It may have access to capacity or management capability which mean the cost of delivering directly for that PCN are less than going with the federation model.  In doing so, the costs of using the federation model are likely to go up for the other PCNs and practices (because the fixed costs are then shared between fewer practices).  But at least our PCN has maximised the potential of the opportunity presented.

Should, then, individual PCNs make decisions based on the direct interest of itself and its member practices, or on the greater good of the wider group of local general practices?

The fates of PCNs and practices in an area are actually intertwined, whether PCNs and practices like it or not.  How much a system invests in local general practice overall will be determined by the extent to which general practice is able to both agree amongst itself and collectively deliver.  A system is not going to choose to invest in the medium to long term into one PCN over and above the others in an area, because it will want gains to be delivered to all of its population not just parts of it.

Choosing to take decisions based on maximising the gains of short term opportunities for an induvial PCN is short sighted, particularly when this comes at the expense of neighbouring practices and PCNs.  Operating in isolation will ultimately come at a cost to overall general practice.

What Michael Jordan said applies directly to practices and PCNs within a local area, “If you think and achieve as a team, the individual accolades (gains) will take care of themselves”.

22
jul
0

Go Back to the Purpose

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We are a year down the line with PCNs.  Recent months have been overshadowed by covid, but there were significant PCN developments in that period.  In particular, the agreement by NHS England to pay 100% rather than 70% cost of the new roles, the rowing back of the service specifications so that now only three (relatively light) specifications need to be delivered this year, and the sign up to the 2020/21 PCN DES by almost all practices.

Last year I don’t think it is unreasonable to say a number of practices, and even whole PCNs, took a ‘wait and see’ attitude towards PCNs.  It was a case of cautious sign up without making any significant commitment.  But now practices are in a whole new position – the role reimbursement scheme funding is significant, the delivery requirement is greater this year, and the extended access funding is around the corner (April next year).  The relative importance, particularly financial, of PCNs to practices is starting to feel different, and so the attitude of practices towards PCNs is beginning to change.

What we are starting to see (understandably) in some areas as a result of this is more unrest within PCNs.  The move from practices taking a relatively passive attitude to one that is more active is inevitably starting to create friction.

This is primarily because GPs and practices often want different things from the PCN.  Should the PCN appoint first contact physiotherapists or more pharmacists?  Should the PCN spend its £1.50 on management support or retain as much of that money as possible for practices?  Should the PCN use the local federation or should it manage its own finances and employment?  There are often different answers to these (and similar) questions within the members of a single PCN.  Moving forward can be difficult.

So how does a PCN move forward in this situation, where practices seem to have differing views on nearly every issue?

The key priority here for PCNs is to work on a shared purpose for the PCN across member practices.  Even if PCNs did this in the early days it may be time now to revisit this given how the landscape has started to shift.  Once there is a clear, shared purpose this can be used as the framework for decision making by the PCN.

Easier said than done.  How exactly do practices develop a shared purpose?  How can practices agree what they want the PCN to achieve?  The key part of this is taking time to sit down together and for each practice to share what they want from the PCN (what we assume is often different to the reality), and then work hard to identify where the common ground lies.

This process may take some time.  The key is to create a framework within which the practices can make decisions together, and criteria to assess any decision against.  If the practices, for example, want the PCN to reduce practice workload, increase the voice of general practice, and improve outcomes for the local frail elderly population, these can become the criteria for assessing any decisions against.  But this will only work if all the practices are agreed and sign up to the framework in the first place, which is why it takes time.

A shared, agreed purpose will not end debates and arguments within a PCN.  There are very few PCNs where the practices agree on everything.  But as the responsibility, funding and influence of PCNs grows, the importance of having a clear direction and a framework to make decisions and settle disputes is greater than ever.

15
jul
0

3 Ways to Attract New Roles to your PCN

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There is a recruitment challenge facing PCNs this year.  There are over 1,200 PCNs, and each PCN has an average budget of £344,000 to spend on new roles.  This converts to more than 7 roles each, and if the time lag is built in (i.e. most of these roles are not yet in post, despite it being July) it could mean PCNs are recruiting to over 10 roles each.

That means there are potentially over 12,000 new roles being advertised by PCNs all at more or less the same time.  That number of viable candidates does not exist, and so the question facing PCNs is why would potential candidates choose their PCN over another?

The nature of the Additional Role Reimbursement Scheme (ARRS) means that the level of funding available to PCNs for the new roles is fixed, so what is unlikely to happen is that the result will be price competition.  PCNs are not going to offer more money to attract the best candidates.

So how can PCNs differentiate themselves?  This might not be as difficult as it at first appears.  Below are three simple steps a PCN can take to give themselves an edge over the competition.

1.Plan the Role in Advance. PCNs are not experienced employers.  The most likely scenario is that most PCNs will do the work as it arises.  That is to say they will first of all advertise the posts and make offers to the best candidate, but only then work out where the role will be based, how it will be managed, and how it will be supported.  Some may identify exactly what work the new role will undertake in advance, but others will only work this out once the new person is in post.

So if a PCN works out in advance both how the post will operate in practice, and how the role will be supported, it is likely to have a huge advantage over many other PCNs.  This means working out upfront where the role will be based, where the clinical work will take place, who will be the line manager, and who will provide professional support.  It means thinking through the mentoring, coaching, education, and personal development support that will enable the new postholder to be successful in their new role.

These things will have to be worked out anyway.  But a PCN that does this before it starts recruiting, and can provide this information as part of its campaign, will be much more attractive to potential candidates than one that plans to wait until the successful candidate takes up post.

 

2.Recruit a Team not just Individuals. Working for the first time in general practice can be daunting for candidates.  Many PCNs will recruit to each of the roles individually.  But if a PCN, or even a groups of PCNs, is recruiting (for example) a team of pharmacists or a team of physician associates, and builds team development and peer support into its offer, it is likely to have an edge.  The postholder knowing they wont be entering this new environment alone, but doing so as part of a team, makes taking on the new role less of a risky proposition.

 

3.Make recruitment personal. Finally, the recruitment campaign itself is an opportunity for PCNs to differentiate themselves.  If PCNs can offer an online platform which provides information about the PCNs and the local area, practices, opportunities and challenges, it is likely to have the edge on many other PCNs.  Even better if it can create a personal connection, e.g. a short video from a GP within the PCN talking about why the role is important, or from a named contact who seems friendly and approachable.

While the bad news is competition is likely to be fierce for the new roles, the good news is that with a little thought and effort your PCN could still be able to attract the best candidates.

8
jul
0

Lessons from AccuRx: Resist the urge to control

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A few weeks ago I wrote about how AccuRx had changed general practice over the course of a single weekend.  What can we learn from the achievements of a relatively small company like AccuRx, in contrast to the traditional ways of working in the NHS?

The most striking feature of the way AccuRx work is that they do not try and control how the innovation they create is used.  Their belief is that if you prescribe how something is to be used, you actually prevent innovation.

The core AccuRx product is the text messaging service.  They linked the service with the individual patient and their record, but didn’t prescribe how or when the service was to be used.  When practices were working out how to see potential covid patients face to face, some put signs in the car parks for patients to wait in their cars until they received a text message when they were ready to be seen.  Not a way of using the product the company could ever have foreseen!  Innovation in the use of the product came from the GPs and the practices, not from the company.

Equally with the video consultations, practices sent the link for the call to a family member who could interpret for the patient when they didn’t speak English.  In hospitals, it was used to enable virtual visits by relatives not able to visit in person.  Innovation was generated by front line staff, enabled by the initial development.

By resisting the urge to control and dictate how the change was to be used, far more innovation has developed as a result.

In general practice local teams in many parts of the country were allowed to work out how to respond to covid.  “Hot hubs” and the like were developed and locally tailored and implemented in days and weeks.  Without central control, frontline innovation prospered.

This is in contrast, of course, to how we normally introduce change in the NHS.  The urge always is to control.  Trusting front line staff to innovate feels risky because it cannot be predicted.  So what we do is insist on business cases that detail not only the change to be introduced, but exactly how it is be used and implemented, and the predicted impact that will result from the prescribed changed.  The more we control the change, the less risk we feel, but at the same time the more we suppress any wider innovation.

Let’s take PCNs as an example.  The basic change is to enable practices to work together and with local partners to improve outcomes for local populations.  But as an NHS we can’t leave it at that, and allow practices to use the change and innovate locally.  The urge to control is too great.  So instead we have template legal network agreements, detailed service specifications (remember the December drafts?), and maturity matrices.  The NHS attempts to control how PCN will operate, what they will do, and the way in which they will develop.

Resisting the urge to control is very difficult in the NHS.  Senior staff are consistently reminded that they are “accountable”.  The pressure to minimise and control any financial risk is immense, and leaves little room for trusting local staff and teams to innovate.  But the lesson from the success of AccuRx is that less control is exactly what is required to foster greater innovation.

1
jul
0

The opportunity of the additional roles for GP practices

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I wonder whether in the all the complexities of the additional role reimbursement scheme (ARRS), the underlying potential value of the new roles to GP practices is being lost.  Are we taking on the new roles so that we can make sure the needs of the PCN DES specification are met, or because the money is there, or because they are part of our strategy to create a sustainable future for our practice?

Just a reminder – despite all the promises of 5,000 (now 6,000) new GPs, and the increases in numbers of GPs entering training, the total number of wte GPs remains (at best) stubbornly static.  In the meantime the workload continues to rise.  While there are pockets of the country that can attract new GPs and do not have a GP recruitment problem, the majority do.  It is no surprise, then, that workload persists as the greatest challenge for the under-manned GP workforce trying to keep up with the growing demand.

If there are no new GPs available, it does seem to make sense to use different roles.  It makes sense from a straight workload perspective, providing much needed assistance to the overall workload problem.  It also makes sense from a financial perspective, as the new roles are generally cheaper than employing GPs, and a lot cheaper than paying for locums.

Life, however, is never that simple.  Resistance comes primarily from the mindset that the idea of the new roles is to allow lesser trained, lower paid clinical professionals to carry out the work of a GP.  It can feel to GP partners when presented with the option of new roles is that the ask is for under-qualified staff to undertake work that requires the skills and training of a GP.  The question appears to be one of whether the practice will sacrifice clinical quality for the sake of financial sustainability and a more manageable workload.

But those practices that have introduced new roles successfully have not used this mindset.  Instead, they have asked what parts of the practice work can be carried out more effectively by a different professional than by a GP.  For example, many practices that have introduced a first contact physiotherapist have found an increase in the quality of the relevant practice referrals to secondary care, to physiotherapy and indeed to self-care.  The same with pharmacists and medication reviews, link workers and meeting the social needs of patients, etc etc.

Ultimately, the aim of the practice is to identify how it can meet the challenge the new profile of demand presents, and consider how it can re-shape the way it meets that demand using the skills, experience and expertise of different clinical staff, so that it can make best use of the available (finite) GP time that it does have.

The opportunity of the PCN additional role funding is that these roles come fully reimbursed.  So not only can the practices in a PCN obtain the new roles they need, they can get them for free, or for whatever minimal contribution is required on top of the ARRS reimbursement.

It is a tremendous opportunity for practices.  I understand practices will have to deal with sharing the roles with other practices, and that the PCN specifications do provide demands on the time of the new clinical staff.  I understand that changing the way the practice operates to make the most of the new roles can be difficult and uncomfortable.  But this could still be a game changer for practices.  It is a chance to put the practice workforce in place that is needed to make the workload sustainable, in a way that it hasn’t been for many years.  I just hope practices work their own way through the challenges and grab this fantastic opportunity with both hands.

24
jun
0

The Future of Federations

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What is the future of GP federations?  Do they have one, or does the emergence of PCNs mean that the days of GP federations are essentially over?

The best place to start when searching for answers to questions like these in the NHS is generally the wider policy context, and this is no exception.  The existing set of GP federations can be by and large split into two categories.  The first set of federations formed in c2007 at the height of the commissioner/provider split, when ‘world class commissioning’ was a thing, and when a primary care provider vehicle was needed for the delivery of services in primary care.

The second set of federations formed 10 years later in c2017 in response to the extended access funding that was made available to general practice and in response to the increasing pressure that general practice was finding itself under.  Funded through the delivery of the access hubs, federations were able to play a wider role in supporting individual member practices.

But the end of the commissioner/provider split was formally (if not explicitly) announced by the publication of the Long Term Plan in January 2019.  It signalled instead a shift to integration.  System Transformation Plans (STPs) were to be implemented and Integrated Care Systems (ICS) developed.

Over the last 30 years a range of GP commissioning organisations have all come and gone, from GP fundholding, through primary care groups and practice based commissioning organisations, right up to the current embodiment as CCGs.  These are in terminal decline, as the NHS moves to replace the legacy of commissioning organisations with the new integrated arrangements.

The new, non-commissioning, integrated entity for general practice are Primary Care Networks (PCNs).  First mentioned in the Long Term Plan published at the start of 2019, they are described as the enabler of “fully integrated community based health care”.

Without a commissioner/provider split, and with the establishment of PCNs as the statutory (or as close to statutory as can be achieved with a set of independent contractors) integrated community provider, it is not clear what role a separate primary care provider like a federation can play.

So far existing federations have been able to co-exist with PCNs, primarily by using the funding in their extended access contracts.  But the funding for extended access shifts to PCNs next year.  While federations will struggle to replace the lost income, PCNs will continue to grow and develop as integrated community providers, with nationally mandated funding streams alongside additional local ones.

It will be tough for federations to continue to exist in isolation from PCNs.  PCNs mean there is no need for a separate provider arm of general practice within an integrated care model, because PCNs are that provider arm.  In the world of integrated care, without the commissioner/provider split, where does an independent provider like a federation receive its funding from?

The future of federations, if there is to be one, can only lie as an enabler of PCNs.  The real barrier to progress for many PCNs is their size, and by working together through a federation they can move faster and more effectively than they can on their own.  Federations could take on delivery of extended access, and indeed of a range of PCN delivery requirements, but only if the PCNs want them to do so.

Federations are currently viable as a result of the provider contracts that they hold.  As integrated care develops, these contracts will shift into the realms of PCNs and the joint working between the statutory providers.  Crunch time is coming soon with the shift of the extended access contracts, and it is hard to see federations surviving it if they are not built on joint working between PCNs.

17
jun
0

accuRx – How General Practice was changed in one weekend

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On Monday 9th March Jacob Haddad, co-founder of accuRx, tweeted, “Friday PM, we decided to build two new products for COVID-19: video consultations and pre-appointment screening. Last night we shipped. This AM we tested. 3pm today, we enabled for 3600 practices – over half the country.”

By the end of April 35,000 video consultations were being carried out by general practice each day, across 90% of practices.  It is unlikely general practice will ever be the same again.

Who are accuRx?  Jacob Haddad and his co-founder Laurence Bargery launched the company in 2016 to develop datasets and tools to help tackle the problem of inappropriate use of antibiotics.  They quickly shifted to the development of a broader communication platform connecting clinical teams with patients.

They started with a text messaging service.  It gained traction quickly, in part because it was offered for free, and in part because GPs found it so easy to use.  It worked effectively with the GP clinical systems and made it easy to text patients where letters and phone calls were proving time consuming and ineffective.

But the game changer was this over-the-weekend introduction of video consultations.  In the past video consultations had been difficult to implement, because it was hard to synchronise timings between doctors and patients, and technical and installation issues often got in the way.  But the accuRx system is simple to use for both doctor and patients.  It makes it easy to switch from telephone to video, and doesn’t require any installation.

It is fair to say that GPs by and large love it.  It is extremely rare for a new technology to get universal uptake so quickly.  Of course the shift was shaped by necessity and the context of the pandemic, but even so it has been an unprecedented change, and one that is likely to shape how general practice operates for years to come.  And it is free: accuRx does not charge practices to use the service.  Apparently some agreement has been reached between the company and NHS England, the details of which are unclear, but it remains free at the point of use for practices and their patients.

accuRx is venture backed.  It raised £8.8M of funding in its last round in 2019, and is in what is termed the “pre-revenue” stage.  How that will play out for the NHS and general practice when it needs to generate revenue remains to be seen.  But the strategy of gaining traction for the product first has had a huge, transformational impact.

It is in direct contrast to GP at Hand, in many ways the initial trailblazer for video consultations.  GP at Hand set up in competition with general practice, using video and e-consultations as their competitive advantage.  They (unsurprisingly) encountered huge resistance, and now their advantage has gone.  While accuRx has thrived during covid, and undoubtedly has the support of the profession, apparently GP at Hand has furloughed 5% of its staff.

When you reflect on the millions and millions of pounds invested in technology within the NHS (NPFIT anyone?) and the tortuous pace of development, it is unthinkable that changes developed by a small team over the period of one weekend could have such a profound and permanent impact on general practice.  But that is undoubtedly what has happened, and general practice will never be the same again.

10
jun
0

Time for Reflection

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I am tired.  It has been difficult over the last few months not only having to keep up with the pace of change, but also having to constantly adapt and get used to new ways of working.  It is not only our professional lives, but our personal lives as well.  Everything we do has been completely changed.  It has been exhausting.

I know I am not alone.  Everyone working in general practice has had their world turned upside down.  All we want is some respite.

The talk nationally is of recovery and restoration.  Sounds like exactly what we need.  But of course it is not about us.  It is about restoring the services that are not being offered, and creating that dreadful term “a new normal”.

It is into this context that we hear about how this is a new future for general practice, how we must build on the changes and go further, faster.

But we are tired.

It may be the start of a new future for general practice.  Or it may be that many GPs are just waiting for the opportunity to close the much-touted new digital front door.  The draw of the comfort of ways of working that we know and trust may well take many back to how things were, not forwards to the newly glimpsed but (for some) highly uncomfortable ways of working we are now experiencing.

Recovery and restoration in general practice needs to start with practices and practice staff.  It needs to be about creating time for teams to reflect on the changes they have made over the last few months, to share the things that been difficult and to ask for help where it is needed.  We need the opportunity to talk to others about what they have done, how they have coped with the changes, and what the impact has been for them.  We want to learn from what they did differently and understand what this teaches us about our own experiences as well as theirs.  We need the comfort of knowing we are not the only ones who have found this difficult, and the reassurance that what we are doing now is ok.

We need time to consider whether any of the changes have been positive, and if they have which ones we want to keep.  We need the opportunity to think this through for ourselves, rather than be told it by other people.  We need to do this at our own pace.

At this point in our covid journey, I don’t think there is anything more important than creating time and space for reflection and review.  We have to recognise that we and those around us are tired, that change is difficult and this feels like it has been going on for a long time.  We need to create the opportunity for ourselves and our teams to be able to move forward.  It may feel counter intuitive, but the way to do this is by creating the time and space for our teams to look backwards, so that we can decide for ourselves where we go from here.

3
jun
0

Are PCNs Making General Practice More or Less Resilient?

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Resilience is a popular term at present, as we all cope with the challenges of covid in our own way.  While our individual levels of resilience may vary, it is not just our personality that will determine our overall level of resilience.

For GPs and those working in GP practices, the robustness of the GP practice itself will be a huge contributor to our personal resilience.  If our practice is well run, has strong leadership in place, and has good relationships across the practice, we can use the practice a resource to help us with the challenges we face.  When we are confident in the strength of the practice as a unit, we can draw on that to help us when things like covid come along.

Conversely, if the practice has divided leadership, poor systems and processes in place, and weak relationships between the staff, then the practice is likely to be a source of worry and concern for us.  The practice itself becomes yet another contributing factor to the stress and anxiety we feel, and so is likely to make us less resilient.

And so the strength of the practice unit is critical to the overall resilience of general practice.  So what impact do PCNs have on the resilience of GP practices.  Do they help, or do they make it worse?

For some practices, the PCN is a real source of concern.  We have seen this articulated in some of the resistance to the PCN DES.  PCNs are designed so that the performance of the individual practice becomes linked to the performance of the other practices in the PCN.  The inability of your practice to control the performance of the other practices in the network, alongside a lack of confidence in their ability to deliver, means the PCN will serve primarily to reduce our confidence in our own practice’s ability to deliver.  Putting performance outside of our individual control is a source of stress and detracts from our overall resilience.

The desire to maintain the independent contractor model in the context of PCNs is about enabling a practice to keep control of everything within its contract, and not allow concerns about other practices to make the job of running your own practice even more difficult.

For others, however, particularly as a result of the recent challenges of tackling covid, the PCN has become a source of real strength.  While I as an individual practice may not have been able to cope with covid on my own, by working with the other practices in my PCN I found support, joint working, and a collective strength that enabled the challenges we faced to be overcome.

By working with other practices I trust I can become more confident in the delivery of targets because I can access the support and help I need when things are difficult or I don’t know what to do.  The PCN becomes a vehicle for sharing of ideas, information and resources that means I feel more confident about my practice, and so more resilient overall.

So are PCNs making general practice more or less resilient?  It varies.  Some practices feel that the PCN makes their practice less resilient, while others are starting to feel that their resilience is very much improved by being part of the PCN.  The most interesting thing about this is that practices control the PCN.  PCNs can support the resilience of general practice, but ultimately it is up to the practices in the PCN to decide to work on building the trust and relationships required to enable this, or whether to resist the PCN, treat it as a threat, and suffer the impact on overall resilience that will result.

27
may
0

The Opportunity of the Additional Role Reimbursement Scheme

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By far the largest amount of funding in the PCN DES is for the Additional Role Reimbursement Scheme (ARRS).  But is general practice making the most of the opportunity that such an investment represents?

To put the funding into context, a PCN with a weighted list size of 50,000 will receive £356,600 under the ARRS.  This size of PCN will have funding for more than 7 roles this year.  This will rise to £618,600 next year, £850,900 the year after, and reach £1.17M in 2023/24 (network contract DES guidance p20). The £7.13 per weighted patient PCNs receive for the ARRS for this year compares to a combined total of £5.61 for all of the other funding in this year’s specification put together (excluding the care home premium, which is not going to significantly alter the figures).

The funding is not, however, given as a lump sum.  It is paid a month in arrears based on the actual expenditure made by the PCN.  A PCN must, “complete and return to the commissioner a workforce plan, using the agreed national workforce planning template, providing details of its recruitment plans for 2020/21 by 31 August 2020 and indicative intentions through to 2023/24 by 31 October 2020” (6.5.1 Network contract DES Specification, p36).

We are currently at the end of May.  Assuming a PCN has not yet employed any additional staff (although I know some have, many have not), our 50K weighted population PCN now has funding for 9.3 additional roles.  If the PCN waits until the end of August (the deadline for submitting its plan), it will have funding for 11.6 additional roles.  The longer we go into the year, the harder it is going to be to spend the money.  Once we are over a third of the way in next year’s funding is unlikely to cover the incurred recurrent expenditure even if we do manage to spend it all.

Any money allocated to a PCN that can’t be spent will be offered to “other PCNs within the commissioner’s boundary”.  So a smart PCN will not only be well into planning how to use its ARRS funds, it will also be looking at its neighbouring PCNs and working out whether they going to be able to use all their funding and preparing accordingly.

This year, impacted already by covid as it has been, does present general practice with something of an opportunity when it comes to ARRS.  In effect there is 12 months funding available for 6 months of work, because the requirements of the specifications only start on October 1st.  The argument has been that the roles should be supporting core general practice, not simply carrying out additional work mandated by the PCN DES.  Well it may or may not be by design, but that opportunity is certainly there now for this year for PCNs.

The question, then, is how should PCNs respond?  With such a wide array of roles (10 in total) available, what roles should PCNs be prioritising?

Let’s take the work to meet the requirements of the specifications as a given, and focus on what to do with the roles beyond that.  The specifications are not going to require all of the ARRS funding, and certainly will not this year.  Once the specification requirements are met, it seems there are two ways to think about how to use the new roles.

The first is to focus on the roles that will free up the most GP time.  The biggest challenge in general practice for a long time now has been GP workload, and so it would be logical to use this funding on the roles that most directly reduce GP workload.  This would lead to a focus on first contact physiotherapists, physician associates, pharmacists and (next year) paramedics, as roles that can directly have this impact.

The second is to focus on the roles that can change the shape of demand into GP practices.  Instead of reacting to the incessant rise in demand on practices, this may be an opportunity to do something about it.  A team made up of some combination of social prescribers, health and wellbeing coaches, occupational therapists, dietitians, podiatrists and care coordinators may be able to start with the currently shielded and housebound patients, and prepare a PCN for the anticipatory care and personalised care specifications that are on their way in future years.  By proactively meeting the needs of those patients who are the biggest drivers of demand on PCN practices, the constantly rising demand may be slowed.

These two approaches are not mutually exclusive.  It may be that some combination to the two is what is needed locally.  And of course there may be others.  What is important for PCNs is to be clear on what they are trying to achieve with the new roles, before they start deciding which specific roles they want to employ.

It is rare that general practice finds itself with an opportunity like this, backed up with such significant resources.  I very much hope we make the most of it.

20
may
0

The impact of virtual working

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The working day has transformed for many people (including me!) in recent weeks, and one of the key changes has been the shift to Zoom (or Teams, or Hangouts, or Skype) video calls for meetings.  Zoom has been a vital part of managing during the pandemic, enabling rapid communication and decision making without the need for in-person meetings or travel.

But how is the shift to Zoom affecting relationships?  While some are reporting that the increased communication means relationships have never been better, others are finding that relationships are beginning to suffer.

There are a number of reasons for this.  Firstly, it turn out that Zoom fatigue is “a thing”.  This HBR article explains that the focus required in video calls, the ability to get distracted by other things, plus the need to be paying attention the whole time, all contribute to this growing phenomenon of Zoom fatigue.  This BBC article (I told you it was a thing) also suggests the need for greater focus means people cannot relax into conversations.

I am not sure it is just about getting used to the technology.  I think the ease with which we can hold the meetings actually leads to more meetings than we had before.  This is quite some feat, given the NHS’s penchant for back to back meetings.

At the same time, there can be something impersonal about Zoom meetings.  This humorous video (which I am sure you have already seen) reduces attendees into certain types.  It does seem to me that it is a difficult platform on which to actively build personal relationships.  Alongside the rapid growth in group video meetings we seem to be having less one on one meetings.  It is so easy to add people into a call that meetings are rarely with less than 4 people, and regularly with many more.  The cost of this is potentially individual, personal relationships.

What should we do?  This National Geographic article suggests when people start to experience Zoom fatigue then they should join meetings with the camera off.  This is because it is far less exhausting to not feel like you are in the spotlight every time you have a meeting.  But then the people with the cameras on assume you are not paying attention and more than likely doing something else.  Once again, it is relationships that can suffer.

And where there are disagreements individuals can often prepared to be much more forceful in their views when they are on a video call (but with the camera turned off) than they would have been face to face.

The basis of collaborative working is relationships and trust.  Communication is a key part of building trust.  But if the communication does not feel personal, is tiring, and even negative or aggressive, then relationships will suffer not improve.   Simply holding more Zoom meetings is not going to improve relationships per se.

I find myself in the camp that would say if you are going to be in a Zoom call then you need to commit to it and have the camera on.  More helpful, then, than the advice to join meetings with the camera off is the advice in this article which suggests 5 alternatives to zoom meetings we might want to try.  These include the “old-fashioned” phone call, holding shorter video conferences, and scheduling days without them.

Ultimately, what I think we need to do is prioritise relationships.  If we are finding that Zoom calls are enhancing relationships, building trust, and enabling collaborative working then great, carry on.  But where we find relationships are starting to suffer we need to take time to reflect on why, and identify what changes we need to make to rebuild those relationships.

Zoom has had a transformative effect on my life in recent weeks.  I am certainly not advocating abandoning something that has had such an impact.  I am, however, suggesting we review its effect on us and our work beyond simple convenience, to ensure it enhances what we do rather than detracts from it.

13
may
0

Holding the Gains

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There is a lot of talk at present about improvements that have been made as a result of the crisis.  These changes include the move to remote working, connected teams, practices working together to create “hubs” for patients to be seen in, data sharing between practices and organisation, and systems working together to make decisions based on needs.  I am sure there are many others.

As a result, exercises are emerging (often management led) in identifying the changes we want to keep, and even considering how we can take these changes even further.

There is a presumption, it seems, that the changes made in response to the crisis, are somehow “locked in” for the post-covid future.  But the reality is of course that change is never that simple.  It would be unwise to underestimate the impact the level of recent change has had on individuals, and the discomfort it has caused.  A change made in response to a national crisis is very different from a change made in perpetuity.  Throw in a bit of conspiracy theory that there is some masterplan to move away from the core general practice model, and it is not hard to understand why holding the gains made so far will be a challenge, let alone building on them.

What do we know about sustaining improvements?  Nicola Bateman produced a guide on the sustainability of improvements made back in 2001.  The research was based on the sustainability of changes implemented rapidly in an improvement workshop, but there is a useful parallel here to changes made rapidly in general practice in a covid environment.

What she found was that there are 5 ways changes can go:

She divided the post programme period into two phases.  The first 3 months is primarily concerned with maintaining the new way of working and resolving the technical issues identified during the initial improvement period, and whether these are tackled and resolved.

The Class A and B classifications closed out the actions on the problem follow-up list and maintained the new way of working.  Class C maintained the new way of working but failed to close out tasks, and Class D activities closed out the tasks but did not maintain the new way of working.  Class E activities failed to do either.

There are lots of interesting lessons in this for us.  Beyond understanding that the only way is not up, it highlights that problems identified along the way to making these rapid improvements still need to be tackled and dealt with.  According to Bateman, they also need contribution and buy-in from the relevant teams, “making sure that the people who work in the area can contribute to the way in which their area is operated”.

A change implemented out of necessity, steamrollering any resistance along the way, will need engagement of teams to adapt that change to give it a chance of becoming permanent.

Bateman also advises, “ensuring that the team members and their managers remain focussed on the improvement activity”.  The idea that remote working (for example) is somehow “done” because it has been going for a few weeks misses the need to be continually addressing issues that arise and adapting it to meet the needs of the practice and its staff.  We are not yet at a point where any of the changes we have put in place so far could be considered permanent.

The second phase Bateman divided the post programme period into was from 3 months to 9 months after the initial changes were made.  This period is concerned with whether there is any ongoing improvement beyond the initial change period.  Class A is what happens when ongoing improvement is in place, as opposed to Class B where there is not.

Being able to make further improvements after these initial gains requires three things: consistency and buy-in; having a strategic direction; and (senior) support and focus.  So making the most of the opportunity that seemingly now exists will be no mean feat.  It will require a practice to adapt its medium term strategic direction, with full buy-in of the GPs and practice staff, and to develop a clear plan for moving forward.

There are five ways we can go from here.   If we are really serious about holding and even building on the gains made in recent weeks then we need to understand there is a lot of work to be done in keeping things as they currently are, let alone taking them beyond the current level.

6
may
0

The Care Home Debacle

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Nothing has gone well when it comes to care homes in this pandemic.  Care home staff trying to look after an extremely vulnerable group of patients have been left on their own, without access to the support, resources or equipment they need.  Figures from the Office for National Statistics show that between 10 and 24 April, there were 4,343 recorded deaths from Covid-19 in residential care homes.  The number of deaths in care homes is rising at a higher rate than hospitals.  Frustration with the lack of support has grown, not just among staff and relatives but more widely across the country.

It is probably in response to this frustration that Simon Stevens announced in his letter to the NHS on Wednesday 29 April, “To further support care homes, the NHS will bring forward a package of support to care homes drawing on key components of the Enhanced Care in Care Homes service and delivered as a collaboration between community and general practice teams. This should include a weekly virtual ‘care home round’ of residents needing clinical support.”

Now anyone paying attention to the events surrounding the 2020/21 PCN DES will have been able to predict the reaction from general practice.  One of the most contentious issues surrounding this year’s PCN DES was the specification that related to enhanced care in care homes with the workload implications it contained for GPs.  Eventually a care home ‘premium’ of £120 per bed was agreed, with a trimmed down version of the specification to be implemented from October 1st, that allowed for “appropriate and consistent medical input from a GP or geriatrician, with the frequency and form of this input determined on the basis of clinical judgement” (as opposed to mandatory GP participation in weekly ward rounds at each home).

But this was a fragile compromise at best, and so it was no surprise that the new announcement attracted a vehement response from the GPC.  Chair Dr Richard Vautrey said the next day, “We were incredibly disappointed to see in the letter from NHS England yesterday that it intends to bring forward the introduction of key elements of the care home specification without engaging with the profession, and in the full knowledge of the serious concerns many in the profession have previously expressed about this earlier this year.  We have told NHS England and Improvement that this approach is unacceptable. The profession will be rightly dismayed that this element of the contract scheduled for October, which depended on an expanded workforce and additional resources, could be imposed without either being provided.”

Cue some backtracking from NHS England.  It turns out that anyone thinking that Simon Stevens letter was about bringing forward the DES specification was wildly mistaken.  In fact, as a letter from NHS England on the 1st May clarified, it is rather a service that needs to be established “as part of the COVID-19 response”.  Of course it not the PCN DES specification, because, “We are looking for all practices to take part, not just Primary Care Networks (PCNs). However, it will be less burdensome for general practice, easier for community partners and better for care homes for this to be delivered at a PCN level as the default.”  What were we thinking?

But however we got here, we are where we are.  If we have learnt anything from coronavirus it is surely that care homes need to be tied much more closely into the health and social care system, and there is a  clear and pressing need right now to provide better support to care homes.  Such a need in fact that NHS England has outlined a two week deadline(!) for the new service to be put in place.

I know there are some places around the country that have tackled this in the past and have arrangements in place that effectively mean all the new requirements are already met.  There are, however, others where there are vast numbers of residential homes and no such arrangements in place.  The challenge in these areas cannot be underestimated.

Let’s hope the wider system puts the support and resources into general practice and PCNs that will be needed for an effective response to be mobilised.  And let’s hope that care homes start to get the support that has been so sadly lacking so far through this crisis.

30
apr
0

Where are we up to with PCNs?

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It has been very hard to think of anything other than covid for the last 6 or so weeks, but it feels like we are now just reaching the point where we can start to consider where other issues are up to.  In particular, PCNs were a controversial topic in the first three months of the year, and the deadline for signing up to the 20/21 DES is fast approaching.  So where did things with PCNs get to?  Time for a recap.

The 20/21 PCN DES got off to a bad start when the draft specifications were published just before Christmas.  What followed was widespread uproar over the level of specificity they contained, the financial implications for practices, and the lack of any additional funding to go with the new workload requirements.

These were only drafts for consultation, and following a torrent of negative feedback the GPC and NHS England commenced negotiations on the new contract.  The result was a reduction in both the volume and specificity of the service specifications (leaving only three: structured medication reviews and medicines optimisation; enhanced health in care homes; and supporting early cancer diagnosis), a commitment to fully fund the new roles (as opposed to providing 70% funding), and additional funding for the care home specification.

What followed this agreement between the GPC and NHS England was a general calming down, and a sense that what was on offer was much more reasonable.  However, underlying concerns about what PCNs mean for the independent contractor model persisted.  These culminated in a vote at the special conference of England LMCs on the 11th March, which decided to reject the agreed DES specification.

Before anyone really had a chance to react to this, covid happened.  Indeed it was only 8 days later that NHS England published a letter detailing further changes to the PCN DES.  These changes were designed to do two things: push the work back until after covid (the start date for the new specifications were essentially all moved to 1st October); and use the PCN DES to release money into general practice to support with the crisis.  The new Investment and impact fund was replaced for its first 6 months with a PCN support payment of 27p per weighted population (not contingent on performance), and the funding for all the new roles (PCNs now have an additional role reimbursement scheme (ARRS) allowance from which they can fund any of 10 new roles) was made available despite the specifications not starting until October.  Indeed all the PCN DES funding has been made available to practices who sign up from April.

These changes were confirmed in the covering letter for the final PCN DES specification which was published on 31 March.  NHS England has been clear that they made sure this came out not because of a stubborn commitment to PCNs, but to ensure that money continued to flow to PCNs in the midst of the pandemic.

So the PCN DES specification is out.  Practices have until 31 May to decide if they want to participate.  Sign up is easy, especially if the PCN is not changing its membership.  Practices simply confirm their ongoing participation to the commissioner.  Once signed up practices remain signed up for the year, and cannot withdraw during the course of the year.

There have been some concerns that by signing up for this year practices are committed for a longer period.  That is not the case.  The system does change to one of opt-out rather than opt-in from April 2021, but the process of opt-out is straightforward.  The practice must simply, “notify the commissioner within one calendar month of the publication by NHS England and NHS Improvement of the specification for the subsequent Network Contract DES” (Network Contract DES Specification 4.13.1).

The GPC are encouraging sign up, as are many LMCs (e.g. Surrey and Sussex).  The rationale is it represents a vehicle to channel funding into general practice in the national effort to deal with the pandemic, and it continues to enable a structure for much needed collaboration between practices to enhance support and resilience for practices at local level.  Other LMCs (e.g. Berkshire, Buckinghamshire and Oxfordshire) remain fundamentally opposed and so are taking a more neutral stance and neither recommending practices sign up or don’t sign up.

So this is where we are.  My 10 cents for what it is worth is that with all the uncertainty that covid brings for the next 12 months this isn’t the time to be walking away.  The PCN DES brings significant funding and resources into general practice over the whole year, while the additional work is only for 6 months (and that is assuming we don’t have any future covid disruption).  Even if you are not sure about PCNs it is not difficult to opt out next year, so you are not making a lifelong commitment.  Covid has changed everything, and the PCN DES is no exception.

22
apr
0

Covid Changes: Opportunity or Threat?

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Rapid changes are taking place across general practice as a result of the covid crisis.  Do these pose a long term threat to the profession, or are they an opportunity?

It is hard to over-exaggerate the level of change taking place in general practice right now.  The shift to telephone consultations, video consultations and remote working, borne out of necessity, is happening at a pace and a scale never previously seen.  Shared models of service delivery across practices within networks and boroughs are being developed and operationalised in a matter of days.  Models include covid face to face sites (“hot” clinics), covid and non-covid visiting services, and even non-covid face to face services, including essential services such as childhood immunisations and routine injections.

Such changes have raised concerns in some quarters of the profession.  Will general practice ever be the same again?  Once this is all over, will things be able to return to the way they were, or are we saying goodbye to general practice as we knew it forever?  The worry is that the scale and pace of the changes being introduced right now will have an impact on the profession way beyond being able to cope with the crisis that is front and centre right now.

It is, however, worth bearing in mind that all was not well in general practice before the current crisis.  The GP Forward View, and then the five year contract introduced last year, were put in place to help a profession that was facing significant workload, workforce and financial challenges.  Some areas had been making changes in an attempt to meet these challenges.  These changes largely focussed on new ways of working, working at scale, introducing new roles, and building stronger partnerships with the wider system.

What the current crisis is providing is a unique opportunity to test out these changes.  The rationale for making these changes is stronger than ever.  Rather than the changes relying on a critical mass of practices having reached the point of enough being enough, when in reality some practices were getting there while others were managing to find a way through, now the need for change is clear.  The safety of staff, and limiting exposure to the virus, requires virtual appointments and centralised models of face to face delivery.  This, alongside the limited supplies of PPE, means these models have had to be put in place very quickly indeed, when previously such changes would have taken months or even years to put in place.

At the same time, the system is providing resources to general practice to make these shifts in ways that it never has done before.  On the podcast Dr Ravi Tomar describes the advantage practices have in making the shift to remote working now compared to when his practice made it 18 months ago.  Laptops, dongles, tokens are all being made readily available to practices.  In many areas centralised models of service delivery for covid patients are being directly funded by the local CCG.

The need for rapid change right now, and the support and resources available to make this happen, represent much more of an opportunity than a threat to general practice.  Once all this is over general practice can choose the parts of the changes they want to keep and the parts they do not.  But right now there is a unique opportunity for general practice, a profession that has been in urgent need of resuscitation, to test out new ways of working.  These changes may not only help it get through the current crisis, but also enable it to thrive into the future.

1
apr
0

What level of risk are we prepared to take on PPE?

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A big part of this week has been about PPE (personal protective equipment).  GPs need it.  They need it to see covid/suspected covid patients, and, increasingly, they need it to see everyone because right now who isn’t suspected covid?

The problem is that the supplies have not been there.  Initial supplies were sent to GP practices in early March.  But these supplies are widely regarded to be inadequate for what is required, and are rapidly running out (if they have not already done so).  Last week GPs were informed that a hotline had been established (0800 9159964 in case you don’t have the number), and for GP practices ringing the hotline that kit would be arranged within 72 hours.  So far (as of the weekend) reports are that problems remain.

As a result, GP federations and organisations have been working to see if they can secure supplies on behalf of their member practices.  Supplies do exist, but they are primarily in China.  But as we have been discovering this week, there are a number of problems dealing directly with suppliers in China.

First, the products need validating.  Just because the supplier says the masks are FFP3 masks does not mean they are.  Someone needs to go and check the products.  But finding someone you can rely on to carry out the validation is difficult.

Second, the PPE products need to be transported from China to the UK.  The cost of air freight is eye-watering.  On top of that the exporters need to have all the correct licenses to be able to ship products to the UK.   There are reports that hand sanitisers and overalls are being stopped at the UK border, and being returned to China as the importers did not have an alcohol or medical supplies licence.  This urgently needs to be addressed, but it falls within the remit of government and is out of the control of GP federations.

Third, the products are expensive.  They are not just expensive – prices are escalating on a daily basis, as the worldwide demand for the products soars.  Not only are they expensive, the Chinese suppliers demand payment upfront.  They hold products that everyone wants, so they can set their own terms.  Their terms are that they will only sell to those who are pay upfront.  Some will only sell to those who provide cash upfront.

However, the NHS does not work that way.  The NHS will not make payment up front ahead of supply.  It, understandably, does this on the basis that any supplier not prepared to extend credit to a state backed entity is a much higher risk of fraud.

So here comes the dilemma. How much financial risk is it reasonable to take to secure PPE supplies for GP surgeries?  Because ultimately we are weighing that risk against the health and lives of our GPs and their staff.  Should the NHS be prepared to say that in these exceptional circumstances we will take risks that normally we would not take, because these are not normal times?  Should government be encouraging and enabling NHS organisations to take these risks?  Or is the financial risk not worth it?

Whatever the view of the wider NHS, a number of GP federations think it is a risk worth taking.  If at the end of the day the PPE isn’t what they said it was, or it doesn’t arrive, they view it as a risk worth taking, because ultimately what we are actually risking is the health and lives of those we are asking to deliver care.

25
mar
0

Make or Break for At-Scale General Practice

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I spend most of my time at present working with a GP Federation in North East London.  What has become clear in recent days is that the crisis we are in is a key moment for the federation.  The role of the federation is, and always has been, explicitly to support member practices and delivery of care to their practice populations.  If the federation cannot support practices right now at the time when they need it most, I don’t think it ever will be able to.

This situation is not unique to the federation I am working with.  I think the challenge equally applies to other federations, to super-partnerships, and even to Primary Care Networks.  If there was ever a time when working together could add value, then it is now.

Individual practices are working extremely hard.  They are trying to get to get to grips with whole new ways of working – some practices have had to move to full telephone triage in a week, when many practices have taken years to make such a shift.  Every day there is a new challenge, with different staff off sick or isolating.  The priority is simply to make it through to the end of each day.

What is the role of at scale general practice?  Things are changing at such a pace that what is needed today might be completely different to what is needed in only a couple of weeks’ time.  But for right now, the role appears to be threefold.  First, identifying what immediate support can be provided to practices.  That could be help with ordering equipment, setting up IT equipment or establishing remote working, help obtaining locums, and directly helping when a practice goes into crisis (as some practices inevitably will).

Second, preparing for what is coming next.  We know the scale of the challenge will increase week on week, certainly for some time to come.  What worked last week may not work next week.  Local at scale general practice has to think about what is coming next, and what needs to be put in place to enable practices to cope.  This might be ensuring robust escalation processes are in place between and across practices, the introduction of “hot” sites, establishing an at-scale visiting service, plus things we have not even thought of yet.  Practices are (rightly) focussing on today, so at-scale general practice has to make sure it is doing the thinking about tomorrow.

Third, ensuring there is two-way communication with practices.  Practices need to have the up to date information on what is happening locally, and at the same time need somewhere to raise questions and concerns.  At-scale practice needs to provide that visible local leadership for practices which is so critical at a time when individual practices could easily feel isolated and alone.

But the challenge this presents for the at-scale organisations themselves should not be underestimated.  They often operate with a very limited number of staff, and clinical leaders in more or less full time roles in practices themselves.  They will also have their own internal challenges with sickness and isolation.  Meeting this challenge will not be easy.

In the coming weeks on the podcast I am going to be talking to Tara Humphrey who is working with a PCN, and we will both share our experiences of working with a PCN and a federation to see whether at scale general practice is able to rise to the huge challenge ahead.

18
mar
0

How COVID-19 is re-shaping general practice

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We have had quite a week in general practice.  The LMC conference voted to “reject the PCN DES as it is currently written” and yet, frankly, it feels like an irrelevance given the unfolding situation with regards COVID-19.

The irony of course is that, just when the profession has chosen to reject PCNs, the need to work in groups of practices has become more important than ever before.  The reality is that many practices will have to close for periods of time over the coming weeks, and so right now need to be working and planning with their neighbouring practices to be prepared for when the time comes.

In turn, this reinforces the point that those who voted against the PCN DES were making.  If Primary Care Networks were genuinely about strengthening core general practice (and there is no better example of the need for this than right now) they would have voted for them.  It is the sense that, as the LMC motion put it, they are “a trojan horse to transfer work from secondary care to primary care” that has caused the disillusionment, not the idea of PCNs or working together per se.

Let’s see where we end up, but it may be that when all this is done and dusted we have much stronger, supportive networks of practices, regardless of whether or not they have signed up to the PCN DES.

At the same time practices have been asked to move to a total triage system (whether phone or online), and to undertake all care that can be done remotely through remote means.  The threat caused by coronavirus means that practices are very keen to move to such a system, to reduce the risk to their own staff as much as they can.

Now this is in sharp contrast to the situation we have had previously, where there has been a relatively slow rollout of first telephone triage and then e-consultations.  What situation will we be in a few months down the line when practices have grown used to operating primarily via remote consultations?  Even at this early stage it is hard to envisage a full regression to the point we were in maybe only as recently as last week.

So right before our very eyes general practice is changing at a pace that it has never changed at before.  It is change borne out of the necessity and challenge the current crisis is placing upon us.  What the service will look like once the dust has settled none of us know, but my guess is general practice will never look the same again.

11
mar
0

Coronavirus: Disabling or Enabling?

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Coronavirus: Disabling or Enabling?

As someone who has worked in Emergency Health and Disaster management situations throughout the world, it would not be unreasonable for me to suggest that crises beget opportunity. Whether it be changes in political power and influence, the displacement of refugees or the rapid development of technology to counter impending threats: There will always be individuals and organisations that can benefit from disaster situations.

Coronavirus presents just such a situation. And whilst not every individual or organisation will stick to the moral high ground when exercising that right, there are plenty of opportunities for well-meaning groups to provide assistance during this current outbreak.

One such group are the emerging Primary Care Networks (PCNs), who are in prime position to grasp this opportunity and respond to this rapidly developing crisis.

Now there is no escaping the fact that PCNs are still new and in varying states of cohesion; there is still wrangling about what is expected of them and the funding that will support them – but none of that matters in a crisis.  None of that matters if you start to dig deeper into the potential community impact of the Coronavirus and Covid-19.

The government is moving to phase 2 of its containment plan ‘Delay’, prompting strategies to defer the impact of Coronavirus beyond the winter pressures by limiting social and occupational interactions and the movement of people. There is no criticism of the strategy per se, but this implies a resignation to the fact that, with the predicted numbers of cases rising steadily, it will no longer be possible to contain the virus simply through contact tracing and isolation within specialist units.

This in turn means that the burden of responsibility for the management of acute cases will fall on other secondary care facilities, which makes it even more vital that there is a robust response to manage cases that present in the community.  There is also an increasing likelihood that patients who might ordinarily require admission may have to remain and be cared for at home or in the community.

All practices are being asked to consider their continuity arrangements and the NHS England Emergency Preparedness, Resilience and Response Framework (2015) highlights the importance of Mutual Aid in successfully managing such incidents.

PCNs are mutual aid units and have a unique capacity to provide such continuity not just within practices but to the community at large.

Staffing

The first consideration when responding to any emergency situation is ensuring the safety of your own workforce.  NHS England guidance for Primary Care (5th March 2020) has provided assurances that sufficient PPE will be delivered to protect staff.  Consider also the existing health needs of your staff and whether their own existing co-morbidities may place them at risk and rotate staff as required.  With an assumption that at its peak 1/5th of workers may be self-isolating, it is vital that a wide range of staff have the capability to manage basic system functions.  If schools are to shut, then some staff will have unplanned caring responsibilities.

Estate

PCNs should consider how they can best use their facilities across a wide area, e.g. some facilities may be easier to clean than others or there may be centres where it easier to isolate patients and keep them away from patients in waiting areas.  At its peak, one practice could be designated for testing.

Service Delivery

Increased demand may mean that existing services need to be rationalised.  Encouraging patients to phone for triage rather than attend the surgery will reduce the risk of cross-contamination. Residential and Nursing Homes may require a PCN to set up a support service using telephone support and risk stratification to identify those most in need of a visit.

Working at scale requires resources to be used in the most expedient way whether it be the deployment of specialist practitioners, the allocation of support staff, the rational use of facilities or the prioritisation of care.

Our nation and the world have been confronted by a new and at times deadly virus. It is vital that we use our precious resources wisely and work together to mitigate its impact.

 

Stephen Kemp works as Senior Consultant for McCartney Healthcare Associates and provides advice on governance, quality and performance issues for Urgent and Primary Care service providers. Stephen is a nurse with 40 years’ experience, mainly spent within Accident & Emergency and Urgent Care. Between 1994 and 2001, Stephen developed health responses to humanitarian crises around the world, including in Rwanda, Afghanistan, Liberia, Mozambique, Honduras and Albania.

4
mar
0

Has the employment liability question been answered?

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The Updated GP Contract states that there are now three measures in position to reduce the risks associated with employment liabilities. This has generally been well accepted and people have moved onto looking at other questions.

Unfortunately, a careful look at these measures reveals very little actual change between the new and the original position.  The three measures represent an option that already existed (measure 1), a partial statement of the law as it has always been (measure 3), and a vague assurance about the future of funding which does not directly give assurances about employment (measure 2).

It is important not to create and continue periods of negativity, and as someone who is generally supportive of the principles underpinning the PCN project it is difficult to appear too critical. However, this has to be balanced by a true understanding of the risks.

If the wrong decisions are taken now, or if over reliance is placed on vague assurances, practices may find their original fears come true.  This in turn creates a further disconnect in the relationship of trust between the practices and the commissioners.

From a practical perspective, I was speaking with a GP partner earlier in the week who had committed to taking on the employment responsibility of all the new staff due to the assurances of the measures. I corrected his view, and this has resulted in a redesign of appropriately shared liabilities across the PCN members.

I have written a longer piece relating to the measures as they have currently been outlined for specific concerns and recommendations. The following is a quick summary of the measures within the updated GP contract:

  • Measure 1 – Using third party contractors

These can be structured in different ways and the extent to which these are provided will vary the degree of protection. They need to be financially viable and should offer the service that you are after. VAT remains a risk if it is not structured correctly. Good contracts are essential in forming these documents.

 

  • Measure 2 – Funding secured within the core contract

This is a good change, but ensure your plans have sufficient security for the employing practices should the money be split between other practices. You may find that you employ an individual but the money is with multiple other practices with no mechanism to claim it. A cross-indemnity arrangement may resolve this risk.

 

  • Measure 3 – Reliance on the future application of TUPE

TUPE has complex rules relating to when it does and does not apply. Most importantly it does not apply where services cannot be clearly defined and employees directly linked with those services. How each specification requirement is structured, and how each additional role is utilised across the PCN, will significantly alter the risk. In many cases it is hard to see how this protection will apply where the team members are integrated into core general practice delivery.

In practice it is important to note that these are the same risks faced by the providers of all time-limited contracts. APMS and AQP providers have had the same issues and it could be argued they have damaged the ability of many of these providers to retain staff and have partially resulted in the higher rates than GMS contracts.

The only definitive solution is a legally binding indemnity from the commissioners relating to redundancies directly resulting from a change of policy. This remains unlikely, and even if it could happen it is some time away.

Practices and PCNs should therefore ensure that this is a defined risk with a suitable management plan based on categorisation of staff. Certain steps can reduce the risk, including the following:

  • Ensure that contracts with third parties are viable in the long-term and that all liabilities are covered;
  • Develop an indemnity between the practices to ensure the funds are appropriately managed, to reduce the risk of funds being split between multiple practices and creating a shortfall for the actual named employer;
  • Where possible, directly link staffing to service delivery. This may reduce flexibility but it improves the chance that TUPE will apply.

Finally, if in doubt seek support when making plans and ensure that you fully understand the risks!

 

Robert McCartney, Managing Director, McCartney Healthcare Associates Ltd.  You can contact Robert by email rm@mccartneyhealth.co.uk.

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26
feb
0

The PCN Clock is Ticking: Your 3 Month Plan

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We now know what is in the GP contract update for next year.  But we are worried that the LMC conference in March might change things.  We don’t know if our practices will sign up again to the PCN DES, and won’t know for sure until the end of May.  So what should we be doing now?

The problem PCNs have, given the challenges posed within the contract for next year, is that they do not have a spare three months.  Meeting the contract requirements is going to take all the time available, and trying to move from a standing start at the end of May is going to make life very difficult for any PCN that postpones taking action.

Where should PCNs start?  It will of course depend on the individual circumstances of each PCN, but a generic plan for the next three months will look something like this:

March

Undertake a workload analysis for 2020/21.  This will include working through the detail of the three PCN specifications, identifying what your “social prescribing service” is going to entail, working through the actions required to achieve the 8 indicators in the Investment and Impact Fund, as well as any actions needed to continue or develop any local priorities or initiatives.

Get the information you need from your CCG.  This will include the list of care homes and number of care home beds in your PCN, the exact amount of your Additional Role Reimbursement Scheme (ARRS) funding for next year, and any additional support the CCG will provide.

Put management support in place.  You may have already done this, but if you haven’t, then now is the time, because the demands on PCNs next year are much more onerous than this year.  Don’t wait until several months in when the PCN CD is on the verge of resignation/breakdown to make this happen.  Use the PCN development money, the £1.50 running costs, or grab any support the PCN is offering – access management support however you can.

Establish your end of 2019/20 financial plan.  By now you will have a good idea of how much money the PCN has spent, is going to spend, and what will be left over.  You need to decide how this funding is either going to be used or distributed to the practices.  You need to do this in March so that if you do want to do anything with the funding it is not too late to make it happen.

April

Define the roles you want.  Once you have completed the workload analysis the PCN will need to decide how to use the ARRS funding to deliver the workload.  PCNs have to formally submit their “workforce intentions” by the end of June, but, frankly, this is too late.

Create a local recruitment campaign.  The contract update indicates that CCG HR resources will be available to PCNs to support them with recruitment into these new roles.  It would seem wise to take up this offer to attract the highest possible calibre of candidates locally.

Establish a financial plan for 2020/21.  As the total income and expenditure will be higher for the year ahead, it is even more important that each PCN establishes not just a plan to deliver the workload and a workforce plan, but also a financial plan to run alongside.

Finalise the 2019/20 accounts.  I can’t stress enough the importance of PCNs sorting out their end of year accounts as early as possible.  If there are any tax implications for the member practices, then they need to be informed of these as early as possible.

May

Push on recruitment.  Recruitment is notoriously slow, and so PCNs will need to make sure the process is being actively managed to ensure the staff they need to enable delivery are in post as quickly as possible.

Prepare for the incoming roles.  Making the new roles a success involves more than simply getting people in post.  PCNs will need a clear plan of how each role is going to be managed, supervised and supported, as well as how they will operate and what they will do.  The better the preparation for the new roles, the more likely that they will be a success.

Create a detailed work plan for each workstream.  PCNs will need to build on the workload analysis carried out in March, and hopefully by now be able to use some management resource, to create a detailed work plan for each of the service specifications and each of the areas of work identified for the PCN.

Sign up to the DES.  At the end of May, practices will need to sign up (or not) to the PCN DES.  If PCNs have carried out all the work above, it will be much easier for practices to be able to understand exactly what is involved and how it is going to be achieved when making this decision.

 

This is not an exhaustive list.  For example, you might want a stakeholder plan (how you are going to work with neighbouring organisations to support/enable delivery of the workload), an estates plan (where are these new roles going to be based), or an IT/data sharing plan (how will you deliver services across multiple practices), depending on your local circumstances.  Equally, you may already have some of the components of the plan in place.  The key point is that the next three months are a vital period for PCNs, and it is important PCNs don’t waste the opportunity to build some momentum into the coming year.

19
feb
0

Is it time to go “all in” on PCNs?

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What is going to happen with Primary Care Networks (PCNs) at the end of the 5 year PCN DES?  Are PCNs going to be a here-today-gone-tomorrow phenomenon, or are they here to stay?  And does it matter?

I think this is a really important question.  It is important because the answer should probably shape how practices approach PCNs, and determine the amount of effort and engagement they put into them.

There are some significant clues in the recently published update to the GP contract.  The update states that the additional roles employed under the PCN DES, “will be treated as part of the core general practice cost base beyond 2023/24” (1.20).  This means £1.13M of additional roles funding (for the “average” PCN) will at that point become part of the core contract.

The Investment and Impact Fund (think QOF for PCNs) will be worth £300M by 2023/24 (£240k per “average” PCN).  This is going to provide population based coverage at a meaningful level within an Integrated Care System in a way that the individual practice QOF does not.  Would it be a huge surprise if future additional investment focussed on the PCN IIF rather than the individual practice QOF?  It would be more of a surprise if it didn’t.

Of the 45 pages containing the details of the updates to the GP contract, virtually half (22 pages) is dedicated to PCNs and PCN initiatives.  The main changes to the GP contract are already now coming through PCNs.  With all the effort and resource that has gone into establishing PCNs and creating them as a platform, it seems highly unlikely that at the end of the 5 years they will be stopped.

More likely is that as the funding for the additional roles shifts into the core general practice contract, so PCNs themselves will shift from being an optional additional service to a core part of the contract.  Despite the nervousness around PCNs that the publication of the draft PCN DES specifications raised earlier this year, the final update reads as though practices and PCNs are already inextricably linked.  And if not now, they certainly will be by 2024.

If you believe this to be true, what does this mean for an individual practice today?  I think the implications are significant.

So far it has been possible to treat PCNs as an optional extra, something a practice can dip in and out of, and leave the work to those prepared to volunteer to take it on.  The implications of the shift signalled in this year’s update are that this level of engagement is no longer going to be enough, because letting PCNs develop in ways that don’t support your practice could jeopardise your practice’s future in the medium term.

Practices are going to have to work to ensure that they are directly receiving the benefit of the new roles and the new sources of funding.  They can’t leave it for others to sort out, and rely solely on the income they receive directly (i.e. not via the PCN).  Over time the PCN will become more established and the ability to shape and influence it will become less for each individual practice.  Practices need to work now to make sure the PCN is working for them and their population.

If I was a partner of a GP practice, my take on this year’s update to the GP contract would be that now is the time to go “all in” on PCNs.  While last year there was probably sense in taking a watching brief to see how PCNs developed, now I think the time for that strategy has come to an end.  The signals are all there that the future of GP funding is going to come through PCNs, and I would want to be right at the forefront of making that work for my practice and my patients.

12
feb
1

What to Make of the Updated GP Contract Agreement

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I am not sure how many of you will have read by now the “Update to the GP Contract Agreement 2020/21 – 2023/24” released by the BMA and NHS England last week, but having waded through all 86 pages it is hard to take it all in. There are huge implications in particular for PCNs, who will need to digest the contents quickly to be able to move to action.

First things first. It looks like the big problems caused by the draft PCN DES specifications have been addressed. The biggest sticking point was no extra money to deliver the required extra work, followed by the seeming requirement that all of the additional roles would be used to deliver extra work and not support core general practice, with practices expected to chip in 30% of the funding for the privilege. The draft specifications were also seen as over-prescriptive, stifling local innovation and responsiveness.

This update addresses these issues in some surprising ways. The number of specifications needed to be delivered in year has been reduced from 5 to 3. Only structured medication reviews, enhanced health in care homes, and supporting early cancer diagnosis remain, with the other four to follow next year (two were always planned to be implemented from 2021). PCNs are also to “provide access to a social prescribing service in 2020/21, drawing on the workforce funded under the network contract DES” (7.5, p41).

100% reimbursement is to be provided for the new roles, removing the need for a 30% contribution from member practices/the £1.50 per head. This won’t solve the problem of being able to recruit into the roles at the funding levels available, but it tackles the major issue of sourcing the 30%. 6 new roles have also been added to the list that PCNs can use this funding to recruit from: pharmacy technicians; care coordinators; health coaches; dietitians; podiatrists and occupational therapists.

Importantly, assurances are made that the funding for these roles will continue in the core GP contract beyond 2023/24, and that should practices withdraw from the PCN DES the roles would TUPE to whichever provider takes over the delivery, alleviating concerns about future liability costs.

Access to further funding is also provided for PCNs. The level of funding available to source these new roles has been increased. Where it was, for an “average PCN”, £206k in 2020/21 it will now be £344k. An additional (recurrent) £120 per care home bed per year will be directly provided.

PCNs can also access funds through the Investment and Impact Fund (IIF). This looks like it is essentially a QOF for PCNs. It is a points based system, with a number of areas each with indicators allocated a certain number of points. There are upper and lower thresholds beyond which no payment is made, with a sliding scale rewarding performance in between.

The “average PCN” can earn £32,400 in 2020/21 from the IIF (although it has to declare it will use any funds earned for workforce expansion and services in primary care). This will rise to £240,000 per PCN by 2023/24. There are 8 indicators for 2020/2021 for seasonal flu vaccinations, LD health checks, referrals to social prescribing, gastro-protective prescribing (3 indicators), metered dose inhaler prescriptions, and spend on medicines that should be routinely prescribed.

The challenge, then, for the PCN is first of all to identify its overall delivery requirements for next year (delivery against the specifications, delivery of a social prescribing service, delivery against the IIF indicators, and any agreed local delivery).

Then the PCN in relatively short order has to establish the additional roles it will need to enable this delivery. PCNs are required to produce (and submit) their workforce “intentions” by 30th June at the latest, but will most likely need to be actively recruiting well ahead of this. The document encourages, in light of the additional role reimbursement funding, PCNs to use the (existing, recurrent) £1.50 to appoint a full time manager and increase PCN Clinical Director time so that the growing PCN workload can be managed effectively. Sounds sensible.

It does seem that there are sufficient resources available in the updated contract to meet the requirements it makes, while at the same time leaving some freedom for local developments, delivery and innovation. This was always the key for me as to whether the revised proposals would make sense.

There is of course more in the update that I haven’t touched on. There is a renewed focus on increasing the number of doctors, with initiatives including a new two year fellowship programme for all newly qualified GPs and nurses, a new to partnership one off payment of £20,000 to encourage GPs to become partners, and a locum support scheme to encourage consistent locum working with groups of PCNs.

We may have a new government but access inevitably features. This year all practices will be required to participate in an appointments dataset, and then it is about preparation for April 2021, by when there will be a “nationally consistent” offer developed for bringing extended hours and extended access funding together, as well as a core digital service to be offered to all patients.

A new payment mechanism for vaccinations and immunisations is being introduced over the next two years. This year it will become an essential service with new contractual core standards that practices will be expected to meet, and an item of service payment of £10.06 introduced for MMR 1 and 2. In year 2 the item of service payment will be expanded to other areas, and a new QOF domain for routine vaccinations will be introduced, with the existing childhood immunisation DES retired.

There are, as ever, a few adjustments to QOF, but that is the bones of the changes within the updated contract agreement. I am sure it will take time to take it all in (especially getting our heads round the new investment and impact fund!), but from first impressions it seems that PCNs may well survive the turbulence of the last few months and be able to build a platform from which they can start to make a real difference.

5
feb
0

It is Not a Race

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I am lucky enough to be in a role where I meet lots of Primary Care Networks in different parts of the country.  One of the most common things they tell me is that they know that they are “behind” where everybody else is.

This is interesting for a range of reasons.  Firstly, if everybody is behind everybody else, who is in front?  The influence of social media is such that when we hear a few PCNs report on what they are doing, our immediate reaction is to think we are not doing that so we must be behind, even without knowing anything like the whole story of what is going on in that other PCN.  By and large we tend to share what we are doing well on social media, not what we are struggling with.

Secondly, what does being “behind” actually mean?  How do we determine if a PCN is ahead or behind?  Is it the extent to which they are meeting the DES requirements, meaning the PCN that has a network agreement, a data sharing agreement, a social prescribing link worker and a pharmacist is ahead, and those that don’t are behind?  I am not convinced this is going to be the best indicator of ultimate PCN success, because it is possible to have all those things in place simply with a level of passive compliance from member practices as opposed to any active ownership.

Maybe it is distance along the PCN maturity matrix that is the best measure of progress?  Just in case you haven’t fully internalised the PCN maturity matrix, it identifies five components of a PCN development journey: leadership, planning and partnerships; use of data and population health management; integrating care; managing resources; working in partnership with people and communities.  Now I wrote back in August about the dangers of a nationally prescribed maturity matrix imposing requirements or expectations on a PCN.  Ultimately each PCN should determine its own purpose, and make its own decision as to what its maturity would look like.

Thirdly, is being ahead a good thing?  If we have learnt anything from the DES specifications it is that showing a little bit of caution may actually be wise in the current environment.

As regular readers will know I am a big fan of Professor John Kotter at Harvard and his approach to change management.  He believes assuming people know that change is needed, and focussing instead on strategy and solutions (like PCNs) is what kills most change efforts.  He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change and make PCNs a success.  There is work for PCN leaders to do to get to this point.

So if PCNs are ultimately an exercise in change management, which is what makes them difficult, then moving too quickly into doing things without spending time coalescing around a shared vision is likely to be a recipe for long term failure.  Meeting contractual requirements, or ticking the boxes on the maturity matrix, are a long way from winning the hearts and minds of member practices and local partners.

PCNs are not a race.  There is no prize for being “ahead” (whatever that means).  Taking time at the start to understand what the PCN is for, and what transformation its members want it to deliver, and building trust across the network (however long this takes) is key to making the most of the opportunity that PCNs provide.

29
jan
0

Extending the Primary Care Network

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What is a network?  According to that modern day fount of all knowledge, Wikipedia, it is, “a set of human contacts known to an individual, with whom that individual would expect to interact at intervals to support a given set of activities. In other words, a personal network is a group of caring, dedicated people who are committed to maintain a relationship with a person in order to support a given set of activities.”

The key point here is that networks are based primarily on relationships.  So while Primary Care Networks (PCNs) may have originated through a contractual route, that shouldn’t be what defines them.  Rather the connectivity, interactions and mutual support of relationships are their lifeblood, and what will determine the impact they can have.

So far Primary Care Networks have, in the majority of cases, been made up of groups of GP practices.  Practices within a network have been building the relationships between themselves to build trust and enable joint working across practices.

But in the Network Contract DES Specification for 2019/20 it said, “There is no requirement for the Network Agreement that is signed by 30th June 2019 to include collaboration between practices and other providers, but this will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated to reflect the new Network Contract DES Specification.” (p11, 3.6).

If we leave the cloud having over next year’s Network Contract DES specification aside for a moment, then the logic of this requirement is sound.  If PCNs are based on relationships, then to make the maximum impact they need to include all those who can contribute to the cause.

But of course there is another way of looking at this.  The reason why practices were uncomfortable signing the network agreement in the first place was the potential impact on the practice’s autonomy.  Practices didn’t want to be told how they would have to operate by the other members of the PCN.  But at least all the other members of the PCN were GP practices, and so there was a level of shared interest.  Widening the membership to include non-GP practice organisations reduces practice autonomy further (less influence on PCN decision making), with less certainty that decisions made will be made in the best interest of my particular practice.

So there are two factors at play here: impact and trust.  For PCNs to have the maximum impact they need a broader set of relationships.  But without trust practices are going to be reluctant to include new members into the PCN family.

Networks must start with a common purpose (clarity on what we are trying to achieve).  Identifying who can help deliver this purpose and widening the membership to include them is the way to move forward.  Let the shared purpose determine the terms of any agreements that need to be made, but prioritise person to person relationships, because it is only when we trust each other that we can work effectively together to make change happen.

The mistake is going to be starting with the network agreements, ahead of building relationships and trust.

PCNs have the opportunity to establish a new way of working for the NHS.  Instead of the traditional top down, bureaucracy heavy, organisation centric way of working, PCNs can model a new style based on trust, relationships and commitment to a common cause.  Whatever the PCN DES specification ends up saying for next year about extending the membership, how PCNs extend their membership is going to be at least as important as who with.

22
jan
0

Is it time to move away from centralised control of PCNs?

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The biggest challenge the publication of the PCN DES specifications for next year has created is not so much the detail contained within the documents but the loss of enthusiasm amongst GPs for the whole PCN project.

Before Christmas there was hope that PCNs could mark a new dawn for general practice.  But that bubble was burst when the specifications demonstrated the lack of any national ambition to use PCNs to support the ailing profession.

Wherever the national negotiations end up, it is hard to believe they will restore the hope and energy that existed last year.  But PCNs don’t go from being a good thing to a bad thing overnight, and so it is worth taking some time to reflect on the opportunities PCNs create, regardless of national specifications.

A good place to start is the time before PCNs existed (remember that?).  There were two main trends in general practice, both a response to the pressures the service has been facing.  The first was the introduction of new roles, not to replace GPs but to manage those parts of the (growing) demand that their skills made them best placed to take on.  The second was the move to bigger practices and operating at scale, to develop the resilience of practices and to enable them to embrace any opportunities that develop.

PCNs continue both these trends.  The majority of the funding for PCNs is for the introduction of new roles, and PCNs bring practices together and provide the opportunity for the benefits of scale to be delivered across practices.

The big new opportunity the introduction of PCNs has created is working in partnership with other providers.  One of the rationales for PCNs was to enable the gap between primary care and the rest of the system to be closed, and to bring (in particular) general practice and community services closer together.

For GP practices PCNs create the opportunity to better meet the needs of the local population.  Practices can clarify what part of the local demand they are best placed to meet, and what part of the demand is best met by partners, by collaborations and by network wide services.  Where gaps in service provision exist PCNs can work with local partner organisations to fill these gaps.

In a world where we didn’t have PCNs what would general practice be doing?  Probably working towards the development of something that looks very much like PCNs…

So the problem is not primary care networks themselves.  PCNs enable general practice to respond effectively to the pressures they face and to better meet the demands they are under.  The issue lies with the PCN DES specifications which seem to be attempting to shift PCNs away from supporting general practice and into the generation of additional work that will make the current problems worse.

But that doesn’t make PCNs themselves a bad thing.  They remain the best hope for general practice for the future.  What has been revealed as the ‘bad thing’ is the level of control the national contract has over PCNs.  Leaving the destiny of PCNs in national hands already looks like a recipe for disaster.  So now may be a good time for practices and local systems to think carefully about exactly how they want to make PCNs work for them, and to exert more local control to restore the confidence of practices that PCNs can still be the path to a bright new future.

15
jan
1

Why the new PCN DES Specification matters to everyone, not just general practice

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There is a huge furore at present in general practice as a result of the publication of the draft PCN DES specification for 2020/21.  There are hugely detailed requirements on PCNs without any additional resource, and a clear expectation that the new workforce outlined in the 5 year GP contract last year is for additional work rather than to help meet the existing pressures in general practice.  Unsurprising, then, that general practice has reacted how it has.

But the implications of the draft specification go beyond general practice.  It is material to whether the shift away from the commissioner/provider split and towards integrated care, as outlined in the Long Term Plan, will succeed.

For integration to have an impact it needs local innovation, driven at a local level, based on trusting local relationships.  But as Integrated Care Systems (ICSs) and Integrated Care Partnerships (ICPs) try to meet testing national deadlines, their focus has shifted to governance, and the traditional NHS focus on accountability, control and decision making.

We have moved the deck chairs around enough times to know already that this will make no difference.  The one opportunity for it ‘to be different this time’ is PCNs.  Their 30-50,000 size enables real localism, borne out of an understanding of what is needed and what will work in each area, with person to person relationships as the enabler of making real change happen quickly.

The job of the architects of the new system really is to create the space, time and freedom for these local relationships to develop, for local problem solving to begin, and for local solutions to be developed.  So, for example, if a group of practices has a problem with the way district nursing is being delivered, instead of them raising that with the CCG to raise with the community trust in a contract meeting, who in turn will raise internally, and very little will happen, we move to a system where the practice leaders meet the district nurse leaders (who they already know) and work out what they can do differently to offer a better service to patients.  A system like this is one where things could start to be different.

The biggest problem with the PCN DES specification is the signal it gives that this will not be allowed to happen.  This is for three reasons.  The first is that if the centre dictates what PCNs should do in anything like the level of detail that is in the draft specifications, local innovation will not be able to flourish.  The mindset of central control has to be given up if integrated care is going to work, because the best solution in one area will not be the same in another, and each area needs the freedom to work out what will work best for them.

The second reason is that it has to be up to local areas to determine how they will use their workforce, and not nationally dictated.  The individual ‘return on investment’ mindset of any new funding, and a requirement for additionality even when core services are floundering, is fundamentally flawed.  We know we are 5-6,000 GPs short.  The new PCN-funded workforce can help both support general practice to thrive and be an enabler for local system working, but it has to be for local areas to decide how this workforce should be deployed across priorities (including core work), not via a nationally dictated contract.  Defining the “additionality” that new roles must deliver misses the point that existing (potentially more important) requirements cannot currently be met, and each local area has to be free to determine how to deploy the new roles to get the most out of them.

The third reason is that it takes time for local relationships to develop.  In year one we have had a primary focus on practice to practice relationships.  In year two we do need to widen that focus to the relationships across the wider group of providers within each network.  Time is needed for trust to develop, and over-burdening local areas with the level of delivery requirements contained in the draft specification at this stage runs a high risk of making relationships worse not better.  We need patience as we build a platform for future success.

My plea is for system leaders to recognise that the underpinning approach encapsulated within the PCN DES specification is one that will prevent the success of the new systems they are trying to create, and that it is not simply a general practice only contractual dispute.  If PCNs are really going to be the engine of integrated care, this contract needs to be an enabler not a dictator of local change.  Getting this contract right is everyone’s responsibility, and it would be great to see local leaders vocalising their own concerns about the issues the draft specification raises.

8
jan
1

What to Make of the Draft PCN Service Specifications

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The draft PCN service specifications were finally released just in time to put a dampener on Christmas for anyone eager enough to read them that quickly.  If you have avoided that particular pleasure so far, you can find them here.

It is worth stating right at the outset that the specifications have been published as draft, and that NHS England is seeking input/feedback from GPs (and “interested parties”), in the form of a survey (which you can access here).  The deadline for comments is the 15th January.  The final version of the specifications won’t be available until “early 2020”, when the contract for next year has been negotiated with the GPC, at which point we can look forward to “further detail for each requirement, followed by guidance”.

There were rumours circulating before these specifications were published that there would be no additional funding attached to support their delivery, and unfortunately these fears have been realised.  The guidance tries to make as much as it can of the existing funding that has come into general practice through PCNs (the practice funding for engagement, the £1.50 per head, and the funding for the new roles). It also suggests £75M will be available via the Investment and Impact Fund, meaning an “average” PCN could secure c£60,000 in 2020/21 via this route.

The problem is this funding has not felt significant to practices this year, and that is without any additional (unfunded) work being included.  More new roles are available to each PCN next year (with associated funding), but each one comes with its own 30% cost, and it is hard to see practices being motivated to put their hands in their pockets to carry out work on top of the work they already cannot cope with.

In an apparent attempt not to “overburden” the nascent PCNs, only two of the five specifications (medication reviews and enhanced health in care homes) are to be implemented in full next year.  The remaining three will be phased in over the next four years.  It seems there is at least some insight behind the guidance of just how these proposals are likely to land with most GPs.

Perhaps this is all an NHS England negotiating tactic.  Perhaps there is a plan to incite general uproar amongst the GP community, which will be quelled by the inclusion of additional resources at a later date.  The request for feedback and inclusion of a survey on the draft specifications does suggest that at least some parts of NHS England understand the implications of asking these specifications to be delivered unfunded.  However, it is entirely likely that senior parts of NHS England think that this is a reasonable ask of general practice, and so I doubt there is a grand plan or that the final outcome is fixed at this point.

It would be a shame if PCNs, who have come an extremely long way in a very short amount of time, are stopped in their tracks by such short-sightedness.  PCNs represent a major change to the fabric of general practice, and it is one that requires much more nurturing to succeed.  Where we are right now is that they are not at the point of irreversibility, and asking too much in too short a space of time without providing the necessary resources is likely to send many areas right back to the beginning.

But these are not the final versions.  As yet nothing is fixed in stone, and there is a whole round of contract negotiations to go through yet.  My advice to GPs is to send comments in nationally and to your local LMC.  Use the survey, although if doesn’t allow you to say what you want to say send your comments directly to england.networkscontract@nhs.net, and include what is needed to make delivery achievable.  Let’s not give up just yet, and let’s see if something positive can be salvaged out of what is admittedly a less that promising start.

Happy new year to you all!!

18
dec
0

Guest Blog – David Cowan – A link worker has arrived. What do I do with them?

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A number of new roles have been introduced into primary care over recent years. In this blog, I’ll focus on two ways that social prescribing is delivered, in particular, the active sign-poster referred to here as a care navigator, and the social prescribing link worker.

Care navigators are often primary care reception staff who have received appropriate training on options they can provide patients. The care navigator role should be seen as complimentary to social prescribing when viewed in terms of ‘as well as social prescribing’ not ‘instead of social prescribing’ (NHSE, Social Prescribing and Community Based Support 2019).

The four levels of social prescribing

Social prescribing as care navigation was identified as the first of four levels by Kimberlee (2015), who notes a growing evidence base for providing online information or leaflets in GP practices to help patients choose the most appropriate service.

The key aspect of differentiating the care navigator role, from other types of social prescribing, is the time the care navigator has with the patient. For the care navigator, it’s often a brief intervention with 30 seconds to a couple of minutes for the care navigator to identify the need and, if appropriate, offer the patient a choice between a GP appointment and an alternative healthcare professional.

Kimberlee (2015) goes on to say that ‘social prescribing light’ was the second level, led by the voluntary sector, including providing a point of contact and addressing a specific need, but no direct links with general practice.

‘Social prescribing medium’ is the third level identified by Kimberlee (2015) and includes a health-focused role, with a set number of visits, addressing healthy lifestyle choices through applied behaviour change techniques.

Finally, the fourth level of social prescribing identified by Kimberlee (2015) is ‘social prescribing holistic’ with a direct primary care referral to social prescribing link workers who may be based in general practice, but are employed by a local social prescribing community provider and focus on the persons self-identified needs.

What is the evidence social prescribing works?

Social prescribing can reduce demand for GP appointments.

A recent study published in the BMJ open journal by Kellezi et al (2019), asked 630 patients to complete a survey at the point of referral and again four months after they had received social prescribing.

There was a reported 25% reduction in healthcare appointments and decreased feelings of loneliness.

Dr Chris Dayson from Sheffield Hallam University has contributed towards the evidence base with several evaluations in Yorkshire, such as in Rotherham in 2014, Doncaster in 2016 and Bradford in 2017. These evaluations show a return on investment to the healthcare system, reductions in primary and secondary care demand as well as improvements in individual mental wellbeing scores.

Despite this, social prescribing evaluations often draw criticism for their lack of methodological rigour (Evidence to Inform the Commissioning of Social Prescribing, 2015).

Social prescribing, as signposting or care navigation, builds on the GP receptionist role, who for many years have helped patients choose a doctor or nurse appointment.

As the extended primary care team grows under the NHS Long Term Plan (2019), social prescribing link workers will benefit from spending time with care navigators:

  • By listening to the needs of patients who request GP appointments, they can flag appropriate referrals.
  • Working together GPs, link workers and care navigators can co-develop the systems and processes so that everyone feels confident for direct signposts away from GP appointments to a link worker.
  • There’s also the option of working with a care navigation training providerConexus Healthcare have trained over 10,000 care navigators across England and Wales, with an accredited care navigation training programme. Appropriate training and support is available to social prescribers with the introduction of a level 3 social prescribing qualification.

So, in a nutshell.

Working together, care navigators and link workers are able to play a greater role in helping patients access social prescribing.

So Mr Williams can directly access a social prescribing link worker, via a care navigator, for welfare and benefits advice. Miss Jenkins can feel less anxious about her housing issues because she’s being supported through each step of talking to her housing association. And Mrs Rupinder could wait just days, rather than weeks, to get extra help with her carer duties, thanks to both a care navigator and link worker.

An integrated care navigation and social prescribing service in primary care makes perfect sense. Patients can get the help they need sooner without the need to see a GP first and save finite GP appointments for patients with medical needs.

Dayson, C. (2014) The Social and Economic Impact of Social Prescribing. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact-rotherham.pdf

Dayson, C. (2016) Doncaster Social Prescribing Service. Understanding Outcomes and Impact. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-doncaster-social-prescribing-service.pdf

Dayson, C. (2017) Evaluation of HALE Community Connectors. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-HALE-community-connectors-social-prescribing.pdf

Evidence to Inform the Commissioning of Social Prescribing (2015) University of York. Centre for Reviews and Dissemination. Available from: https://www.york.ac.uk/media/crd/Ev%20briefing_social_prescribing.pdf

Kellezi et al (2019) The social cure of social prescribing: a mixed-methods study on the benefits of social connectedness on quality and effectiveness of care provision. BMJ Open Journal. Available from: https://bmjopen.bmj.com/content/9/11/e033137

Kimberlee, R. (2015) What is social prescribing? Advances in Social Science Research Journal. Vol 2, No 1. Available from: https://blogs.ncvo.org.uk/wp-content/uploads/2016/02/what-is-social-prescibing.pdf

NHS England (2016) High Impact Action Case Study. Available from: https://www.england.nhs.uk/publication/west-wakefield-reception-care-navigation/

NHS England (2019) Social Prescribing and Community Based Support: Summary Guide. Available from: https://www.england.nhs.uk/publication/social-prescribing-and-community-based-support-summary-guide/

NHS England (2019) Long Term Plan. Available from: https://www.longtermplan.nhs.uk/

11
dec
0

Lessons for PCNs: Get Some Delivery Capacity

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“To me, ideas are worth nothing unless executed. They are just a multiplier. Execution is worth millions.” – Steve Jobs

We could debate whether or not Primary Care Networks are a good idea, but the idea contains enough potential (practices working together, general practice partnering with the wider health and social care system, a focus on the specific needs of a population of c50,000 etc) to state that their success will not be determined by how good the idea of PCNs is, but by how well they are delivered in practice (or “executed” in Steve Jobs parlance).

Lots of people have good ideas.  Some people think their ideas are so good that they pay for a patent on their idea, so that other people can’t steal it.  Forbes reported that, ‘of today’s 2.1 million active patents, 95 percent fail to be licensed or commercialized’.  Most ideas stay as simply that, ideas, and never become a reality because they are never executed.

PCNs are an idea.  At present they exist in the conceptual, and in nascent governance frameworks, but try asking a hospital consultant what a primary care network is.  Their success will not be determined by the size of the population they serve, or whether they have a network agreement in place or have appointed a Clinical Director, but by whether they actually start to deliver and make change happen.  PCNs are still an idea needing to be executed.

Studies into successful change in the NHS have found that there are three critical components of success: clinical leadership, senior support and project management.  Clinical leadership in PCNs comes through the PCN Clinical Director, who has dedicated time to undertake this role (although last week we discussed the importance of protecting this time to make change happen).

Senior support in other organisations of the NHS usually comes from a director who can link the change effort with the organisation’s priorities and the wider senior team.  For PCNs this role can be fulfilled by the PCN Board, who generally have partner level representation from all member practices.

The third component of successful change is dedicated delivery capacity in the form of a project manager.  It is extremely difficult when a PCN CD only has a couple of sessions a week, and practices are working on top of the pressures of the day job, for changes to be made and new ways of working to be introduced.  Change, as we have discussed many times in this blog, is hard, and without dedicated project management it is very difficult to find the capacity to overcome the blocks that will inevitably emerge along the way and make it happen.

While project management for PCNs is not directly funded within the contract, the good news is that PCNs are all being given significant development funding, that will continue over the five years of the contract.  My very strong advice is that PCNs prioritise the use of this funding to establish capacity to deliver change and employ dedicated project management support.

I have met a number of different PCNs on my travels over recent months, and one thing I have noticed is those PCNs who have dedicated delivery capacity in place are the ones who have been able to achieve the most.  The real value of PCNs comes with their ability to execute.  At this point in the development of PCNs, when moving from idea to execution is the critical next step, there can be no higher priority than getting in some dedicated project management support.

4
dec
0

Lessons for PCNs: Learning to Say No

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“It is only by saying ‘no’ that you can concentrate on the things that are really important.” Steve Jobs

I was talking to a PCN Clinical Director recently, who told me the story of how in one day she had received three emails and numerous phone calls, including to her practice receptionists, for her to say whether or not she was employing a link worker.  She and her practices remain undecided on how to progress with link workers (because they are clear they want the model of social prescribing to drive the employment of the team, not vice versa), but she is coming under increasing pressure to 1) spend more and more time responding to these types of process request and 2) put the needs of the system (and its targets to employ link workers) over the needs of the network.

I was talking to a different PCN Clinical Director who told me that he had received an email with a long list of meetings the system was expecting him to attend.  These included PCN assurance meetings, integrated care development meetings, and a whole raft of clinical “transformation” meetings taking place at the wider system level.  He felt pressure to go to as many of these as he could, and wasn’t sure whether saying no was an option or whether it was a requirement of taking on the new role.

In fact, I am sure it would be relatively straightforward for any PCN Clinical Director to spend all of their time responding to the constant system requests for information, attending system meetings and responding positively to as many of the meeting requests they receive as possible (although I doubt they would be able to meet all of them!).

The irony of this position is that despite this willingness to comply and respond positively, it will be these PCNs who in the medium term will be judged to be failing.

Ultimately, successful PCNs will be the ones who understand their local priorities, focus on building local relationships (between practices and with their local communities), and, most importantly, learn how to make change happen.  All of these things take time, and PCNs who spend their time meeting the requirements of the system will not have the time needed to do the things that are important.

And so the job of the leader, the PCN Clinical Director, is to say no to the things that are less important, in order to be able to say yes to the things that are.

In a recent conversation I had with Professor Becky Malby (a national expert in these matters, do check out her blog if you haven’t already), she recommended that to ensure PCNs focus on the right things they allocate at least 80% of the agenda time in any PCN meeting to innovation, change or improvement, and that the time for everything else should be limited to 20% of the time available.

For the new PCN CDs I was talking to that kind of prioritisation can feel very difficult.  But learning to keep focussed on what is important, and to say no to the things that are not, is critical for PCN success.

27
nov
0

The future for GP Home Visiting Services?

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The national LMC conference caused a stir in the national press last week when they passed a motion instructing the GPC to negotiate the removal of home visits from the core contract.

Hardly surprising given the timing and the forthcoming election, with each of the main parties falling over themselves to say how many extra GPs they are going to train and recruit should they be elected (Conservatives an extra 6,000 GPs, Labour and Lib Dems an extra 5,000 GP training places).  And of course it was easy for the press to sensationalise the story as an “end to home visits”, and for Matt Hancock to reject that notion out of hand, when that was not what the conference voted for.

So what did they vote for?  The specific motion was:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

  1. Remove the anachronism of home visits from core contract work (passed 54%-46%)
  2. Negotiate a separate acute service for urgent visits (passed 74% to 26%)
  • Demand any change in service is widely advertised to patients (passed 90% to 10%)

Let’s be clear, the motion was not really about the merits or otherwise of home visits.  It was about GP resourcing and workload.  Despite the existing promise of 5,000 more GPs, the number of GPs has gone down while the workload has continued to rise, at a rate exceeding any increase in funding.  And so, inevitably, we end up with motions like this, which are statements that the current situation is unsustainable.

Something needs to be done.  I don’t think many of those at the conference believed the GPC would be able to negotiate such change to the contract, but rather they wanted a line drawn in the sand.

If the contract itself isn’t going to change, what can be done, and can the visiting system be changed to reduce pressure on GPs?

It is interesting that the level of support at the conference was so high (74%) for the introduction of a separate service for urgent visits.  Whilst some portray the debate as one of access versus continuity, this is snot necessarily the case.  Most current visits by a practice will not necessarily be by the patient’s own GP.  There are systems that have developed in different places around the country where a paramedic or nurse practitioner report back into the surgery before, during and/or after carrying out a home visit.  It does seem there is mileage in such a system that could potentially (according to the LMC conference debate) release 2 hours a day of time for practices.

Of course, not all visits are equal.  Many GPs in the debate have drawn the distinction between urgent on the day visits particularly requiring a “convey to hospital or not” decision, and the scheduled complex visits for very frail elderly people, those with severe disabilities, and those at end of life.  An acute visiting service would be for the former of these types of visits only.

What interests me is why practices are not planning to use the new roles coming via the PCN contract to set up such a service.  The LMC conference gave its own verdict on PCNs, passing a motion that PCNs would not reduce GP workload and would not address the workforce crisis.  But if practices chose to use the new PCN roles in the way they are asking for in relation to visits, it does seem as if PCNs could have an impact.

If the conference had slightly amended its motion as follows, NHS England may have potentially been more receptive:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

  1. Shift the requirement of home visits from core contract work to the PCN contract
  2. Negotiate sufficient resources for PCNs to establish an acute service for urgent visits
  • Demand any change in service is widely advertised to patients

Would this, though, have garnered the same media reaction?  Would it have drawn the line in the sand that the LMCs were seeking?  Unlikely.

But do practices within a PCN require such a motion to be passed?  What is stopping them from deciding for themselves that this is how they are going to use the new roles that are being funded within their PCN?  I doubt local commissioners would get in their way.  Indeed, I suspect such an initiative would be welcomed, and could even attract additional local resource.  The bigger barriers are internal: the change capacity within PCNs; and of actually making change happen across multiple practices.

Relying on the promises of the major political parties to resolve the challenges in general practices is unlikely to be any more successful in the future than it has been in the past.  Whatever the right changes to make are, the best ones are going to come from within the service itself.  If 74% of an LMC conference believe an acute visiting service will help, maybe now is the time to push ahead with its implementation.

19
nov
0

A Network of Primary Care Networks?

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Is a network of primary care networks (PCNs) a good idea?  What are the benefits, and why is operating a network of PCNs more difficult than it might at first appear?

It is only a couple of months ago that practices divided themselves into groupings along PCN lines, and the scars in some areas are not yet fully healed.  So it is with understandable trepidation that some PCN Clinical Directors are thinking about whether operating as part of a network of PCNs is something they really want to be part of.

The rationale for PCNs to work together is fairly solid.  There are (at least) four good reasons to do it.  First is simply for support.  PCNs are new entities, and many Clinical Directors (CDs) are new to such a leadership position.  By working closely with other PCN CDs, they can make sure they understand what is required of them, how (and whether) to meet the various asks the system is putting on them, and can share intelligence as to how to meet the different PCN requirements.  There is a safety and security in numbers, and operating together reduces the risk of your PCN becoming isolated, of making unintentional errors, or of being singled out by the system.

Second, working together as network of PCNs creates a greater capacity to meet the ever-growing demands the system is placing on this new cadre of leaders.  If one PCN CD can attend a meeting instead of five, the collective group of PCN CDs is better able to manage the workload between them, and protect precious time for building relationships between practices within the PCN.

Third, the collective voice of all the PCNs in an area speaking together is much more powerful than that of any individual PCN.  Indeed, if one PCN says one thing and then is directly contradicted by another, the overall voice of local general practice is weakened and the potential influence of the new PCNs hugely reduced.  But if a network of PCNs can agree a position, it can be hugely influential on the CCG and wider system.

Finally, the level of resources provided to PCNs is small compared to the asks that are being made of them.  By sharing resources, e.g. administration, finance, recruitment, training, HR (etc), the PCN pound will stretch much further, and the benefit to practices and ability to deliver significantly increased.

If the benefits are so clear why, then, is not every PCN already operating within a network of PCNs?  Indeed, why is it that in some places where such alliances across localities previously existed, they have they fallen by the wayside with the advent of PCNs as more formal entities?

Essentially, it is a question of trust.  For example:

  • Do I trust the other PCN CD to speak on my behalf and adequately represent my PCN?
  • Do I trust the other PCN CD not to take advantage of any opportunities for their own PCN, before sharing any relevant information with me?
  • Do I trust that the decisions the other PCN CDs will make are the best ones for practices? Or that if I make a decision that is worse for my PCN but better for the wider group, when the scenario is reversed the other PCN CDs will equally make the same decision?
  • Do my practices trust me to make the right decisions when it comes to the other PCNs? Will they back me if I choose for us to be represented by a different PCN CD? Isn’t it safer to make sure I represent my practices directly?
  • Do I trust that I am getting a fair share of resources that are shared?

With sharing comes a loss of control.  Giving up control in this way requires trust.  The benefits of PCNs working together in a network of networks may be obvious, but without trust it is very difficult for them to be realised.

 

13
nov
0

Mind The Gap!

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A gap has developed between CCGs and Primary Care Networks (PCNs).

It is not hard to understand why this has happened.  PCNs formed as a result of the national GP contract agreement, and not as a result of commissioning decisions by the local CCG.  Indeed, many CCGs had local primary care development plans in place involving “localities” that were somewhat derailed by the imposition of PCNs via the national contract. The core funding for PCNs comes through the national contract, and it is the national requirements of the PCN DES that practices that have signed up to meet.

Meanwhile local CCGs and STPs have incorporated PCNs within their overall system development plan.  For many, they are the centrepiece of the out-of-hospital plan for the new system.  PCNs in these plans go way beyond groups of practices, and include a whole range of NHS, community and voluntary sector organisations working together to transform care and outcomes for patients and local residents.

But, frequently, the system has not discussed these expectations with the nascent PCNs themselves.  It has not worked to get any agreement about the role that it would like PCNs to play in the future with the new PCN leaders.  Instead local systems seem to be relying on an assumption that because the national framework agreement exists, the PCNs will then function and develop in the way the local system wants them to.

And so we have a problem.  The expectations the local system has of PCNs (to play its role as defined by the local plan) is significantly different to the expectations local practices have of PCNs (to meet the requirements of the PCN DES).  Throw into the mix the issue of overall sustainability of general practice and where PCNs sit in relation to that (where nationally it is not clear let alone locally) then it is not hard to see why this gap between CCGs and PCNs has developed.

This manifests in lots of different ways.  Take the new roles.  There is a gap between the expectations and issues for practices about the introduction of the new roles through PCNs and those of the system.  Practices are concerned about making up the 30% shortfall in funding, about potential liability for the roles if the funding stops after five years, and whether the roles will create rather than reduce overall GP workload.  The system wants to ensure all of the funding for new roles is utilised, that the new roles support the delivery of local plans, and that moving staff into the new roles does not destabilise any local organisations or departments (e.g. the ambulance service, the physiotherapy department).

At the same time many CCGs are in the throes of merger, and moving into larger organisations more distant from individual PCNs.  Without action it is easy to see this gap getting larger and more problematic.

The need to close this gap is urgent.  Many areas are shying away from an honest conversation between PCN leaders, the LMC, and the CCG because it is difficult to get to a shared place on what is, for example, the future of access hubs given the national framework, or the need for a multi-agency PCN board when there is no current national requirement around this, or even what realistic expectations of PCNs are given their limited capacity.  Too often local systems are over-reliant on an expectation that national directives will close this gap for them, when this rarely proves to be the case.  With the gap widening seemingly with every passing week, this conversation, or series of conversations, is both essential and urgent.

6
nov
0

Is the system suffering from “Shiny New Toy Syndrome”?

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If you are not familiar with shiny new toy syndrome, it is characterised by the sufferer wanting to own the latest toy and getting hooked on the intense but very temporary high of the ownership, before moving on to something else.  In the short term the new toy always seems to offer some sort of novel nirvana and the hope of short term gains, and the owner is blinded to the obvious shortcomings of that item.  But then, inevitably, disenchantment sets in, and the owner discards the toy and moves on to the next thing.

It seems to me that at present the wider NHS system is suffering from shiny new toy syndrome when it comes to Primary Care Networks (PCNs).  Whatever the current question, at present the answer is “PCNs”.  From “how will general practice be sustainable in the future?” to “how will we sort out out of hospital care?” and right through to “how will we deliver our ICP plan?”; the answer always seems to be “PCNs”.

As happens with shiny new toy syndrome, the system is apparently blinded to the obvious shortcomings of PCNs, most notably that they are brand new, they have very limited (if any) capacity to deliver, they have a large cohort of inexperienced leaders in place, and the relationships they have are very much in their infancy.  PCN development money is not, unfortunately, magic dust that can make these limitations disappear any time soon.

And it does not take someone with particularly well-honed psychic powers to predict that a year or two down the line widespread disillusionment with PCNs will set in, as they fail to deliver “what we expected”.  This will be followed by questioning as to whether the 30-50,000 population was really the right size, and then a new solution (or shiny new toy) will be put in place to replace this one, with equally unrealistic expectations upon it.

Success generally comes by staying focussed over the long term, and not getting distracted by whatever is new today.  The risk is that in the excitement of PCNs the recent good work that had been put in place to turn round the fortunes of general practice may get lost, including:

  • The GP Forward View and the releasing time for care programme
  • The support for individual practices to meet the challenges they face
  • The support for practices to learn to work together in different ways
  • The support for federations and other at-scale structures as enabling entities operating across multiple practices.

These were things making a difference, and you can feel the system losing its appetite to maintain its focus on them because PCNs are the shiny new toy in town.  Of course PCNs are an opportunity to build on the work so far, to enable further investment where it is needed into general practice, and to develop stronger relationships across general practice and between general practice and the rest of the system.  But it is going to take time.  The benefits will only come over the medium to long term, and they will require PCNs to build on the progress to the point at which they were conceived rather than starting all over again.

Right now what is important is that unrealistic expectations of PCNs are challenged both nationally and locally to give PCNs the chance to grow and develop.  The system needs to move away from shiny new toy syndrome and develop a long term commitment to PCNs as they have been configured, accept the real benefits will come some years down the line, and understand that the best way of accelerating this development is to build on the work already carried out rather than starting all over again.

30
oct
0

Are you ready for Babylon?

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Any reports of the demise of GP at Hand as a result of the new requirements on it from next year are, at best, overstated.  More likely is the threat to local practices will be greater.  The question, then, is how should practices react?

From April 2020 when the number of out of area patients in any CCG area reaches a certain threshold (1,000 patients) the GP at Hand contract will be split and a new practice list will be created with a new CCG contract, where the company will need to provide premises, be part of local networks, and meet all services requirements.

At present GP at Hand exceed the threshold in at least 17 of the 32 London CCG areas, and there are reports that it won’t be long until this is the case in all 32 areas.  And it is not just London.  In February this year NHS England approved plans for the expansion into Birmingham, and only a few weeks ago the company announced plans to expand into Manchester.

While the suggestion is that GP at Hand will need to set up under new APMS contract arrangements I think this is unlikely.  My sense is they will instead seek to “partner” with an existing practice in each of the relevant areas (and rumours abound these discussions are already taking place).  This removes the need for any set up costs, or any of the recruitment problems that new APMS contractors generally face.  And of course, the ‘local practice’ label could accelerate further the expansion of the service beyond its current rate by giving it a credibility that an anonymous national organisation wouldn’t otherwise have.  Patients not prepared to de-register from their existing practice to register with an on-line provider may not have the same qualms about shifting to the practice down the road.

Will GP at Hand be able to find local practices open to their advances?  Given the challenging environment general practice continues to find itself in, it is hard to imagine there won’t be at least some who will find the promise of silver too hard to resist.

The main challenge this creates for practices is they rely on risk pooling and cross subsidy, where the capitation fee for younger, fitter patients funds the cost of caring for elderly and complex patients.  The way GP at Hand operates, as Hammersmith MP Andy Slaughter describes it, “is distorting the way primary care is going to operate by sucking the most profitable parts into a parallel digital system”.

How, then, should general practice respond?  There is going to be limited political support, as the Secretary of State for Health proudly announced at the RCGP conference last week he was a GP at Hand patient.  If the argument isn’t going to be won at national level, it may well fall to local areas to take up the fight.

But can local areas do anything with the prospect of such a juggernaut looming large?  Even though the situation might feel hopeless to some, there a number of factors working to the advantage of local practices:

  • Consistently over 90% of patients say that they trust their GP, and there is not a clamouring from patients to move to a new service. If practices can keep patient satisfaction high, it is unlikely patients will leave en masse.
  • The opportunity now exists for practices to put their own digital arrangements in place. In the new contract practices have to offer online consultations by April 2020, and so practices can significantly reduce the differential between the local offering and the GP at Hand offering.  Practices working together in Primary Care Networks (PCNs) provide the opportunity for practices to do this collectively, in a way that is tailored to the specific needs of their local population.
  • Local practices are embedded in local communities. PCNs provide an opportunity for practices to strengthen these links further, and to create more reasons why being part of a local service is better than being part of a corporate, national service.
  • LMCs have a role to play. There may not be national opposition to the roll out of GP at Hand, but practices need to be making sure their local LMC is mobilising opposition locally. GP at Hand may come in the package of a local practice, but it is up to the local GP leaders to ensure the local population is fully aware of the reality of the new situation.

There are probably lots of other factors that I have missed.  My point is that Babylon is coming, and it is important practices understand what is on the way, and think proactively about what they can do to minimise the impact on their own practice.  The head in the sand approach is unlikely to be the best one, and now is the time for local practices to get together and come up with their own plan to mitigate the forthcoming challenge.

23
oct
0

What single thing can have the biggest impact on GP resilience?

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I was talking recently to Dr Rachel Morris (who as many of you will know is a Red Whale presenter, coach, and specialist in resilience) as part of a conversation for her new podcast “You are not a frog” (which focusses on how to build resilience and thrive in challenging environments).  General practice is certainly challenging, and the question Rachel asked me was what can GPs do in such an environment?  What “quick wins” are there that GPs can take?

I reflected on all of the guests we have had on the General Practice podcast, and what is clear is that there are no magic bullets for general practice.  Changes that have worked for some have not worked for others.  Some practices hate telephone appointments, some swear by them.  Some love new roles, some think they simply add to the overall burden of work.  Some like to give the admin team more of the GP workload, but others find the lack of control adds to rather than reduces their stress levels.

There is, however, one thing that GPs who are working in practices that are thriving in the current environment have in common: the ability to make change happen.  I don’t think it is over-stretching it to say that a key part of developing resilience for GPs is the ability to make change happen in their own practice.

I recently interviewed Dr Liz Phillips on the podcast, and she talked about the transformational impact being able to make changes (for her as a partner, compared to 12 years previously as a salaried GP) has had on her.  Longer time listeners to the podcast may also remember the inspirational Dr Farzana Hussain talking about how learning how to make change happen using quality improvement techniques had given her the strength to carry on when she was left as the sole partner in her practice.

Resilience comes from the sense of control that when things are not working, they can be made better.  When problems are being faced, there is a way out.  When making change feels impossible, it is easy to understand why individual GP resilience can suffer.

Recently on the podcast Paul Deffley (in a must-listen episode) described his experience of making changes across multiple practices.  However, it was in his first appearance on the podcast that he described an experience of two practices introducing the same pharmacist to do exactly the same things.  One had made it work really well, one hadn’t.  The pharmacist was the same, and what the pharmacist was doing was the same.  The variable was the practices.  Why would one practice be able to introduce the change successfully and the other not?  Ultimately it came down to ability of the practices to make change happen.

Making change is difficult.  But it is not impossible.  Learning how to make change is a skill, and it is one that it is worth investing in developing because the benefits are so wide-reaching.  I remember my own ‘a-ha’ moment many years ago, when suddenly after 5 years of “managing” in acute hospitals I learnt the role was not simply to keep things going, to do the heavy lifting for a period of time until it was someone else’s turn, but to actually make things better.  I learnt the skill of making change happen, and it completely transformed my own experience of being a manager.

So when Rachel asked me what can GPs and practices do that will make the biggest difference in the challenging environment of modern day general practice, my response was to learn how to make change happen.  Whatever the challenges a practice might face, if it knows how to implement change effectively it will always have a route to overcoming them.

16
oct
0

Guest Blog – Karen Castille – 10 things coaching can do for you

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When your car won’t start you probably call out a mechanic. And when your drain is blocked it’s likely you’ll need a plumber to help you unblock it. But when might you require the help of a coach? Whilst it’s hard to describe what their role is, it is certainly not to fix things for you!

As it is notoriously tricky to explain what a coach does, it is probably better to flip the question and, instead, describe how the process of coaching might help you.

The coach’s job is to help you move closer to achieving things you want for yourself. However, most of us have a natural tendency to focus on problems rather than on bigger more strategic and longer-term goals that will help us to grow and learn. So I use the mnemonic ‘A.C.E.’ as a reminder of the three possible areas of focus if you work with a coach:

A – an Aspiration, goal or dream that you have

C – a Challenge, problem or issue that you need to rise to or resolve

E – an Experience or event that you want to make sense of

The ‘A’ is future focused; the ‘C’ is mostly present focused; and the ‘E’ focuses on the past.

Based on many years of coaching, here are ten things that most of my clients ask for help with and which usefully describe how a coach might help you.

Aspirational Things (hopes, dreams and longer-term goals)

1. Provide clarity about what you want, then create a tangible plan of the steps you will take to get there.

2. Work out what’s most important to you (rather than focus on the urgent things in front of you now), especially those things that will help you create a more positive future.

3. Determine what success looks like (for you) and embed this into your longer-term goal.

4. Create excitement, momentum and focus to help you move closer to your goal.

Challenges

5. Build confidence and competence in solving your problems and making decisions about things that are troubling you or keeping you awake at night.

6. Help you to stand outside of the problem, rather than being in it, by questioning your assumptions and helping you think about it from different perspectives so that you can consider different solutions.

7. Work out your options – especially if you feel stuck or that the challenge is impossible to overcome – then create commitment to acting on one or more of your ideas.

Experiences or Events (either negative or positive)

8. Reflect on and make sense of past experiences or situations. This can help you to learn from mistakes and let go of things that are out of your control.

9. Help you discover things about yourself that you may not be conscious of such as:

  • Your leadership style and preferences
  • How you deal with challenging behaviour or conflict situations
  • What works for you (and what doesn’t!)

10. Build positive and productive relationships – even with people you don’t get along with – by reflecting on their behaviour as well as your own.

People who have undergone coaching often talk about it being a life changing or transformational experience. But don’t misunderstand me. It is certainly not a cosy chat over a comforting caramel latte! It requires hard brain work and for you to take responsibility for your life and your future. It needs courage to try new things, and commitment to make changes to the way things are.

This said, when the coach and coachee work well together, it is certainly worth the effort.

Unfortunately, you’ll still need to call out a mechanic for your car, or a plumber for your blocked drain. But with coaching, futures get sharply defined, careers get changed, problems get solved, work-life balance can be restored and, importantly, sleep comes more easily!

Dr Karen Castille O.B.E, Executive and Leadership Coach, Author The Self-Coaching Workbook, @karencastille

9
oct
0

Are PCNs the new unit of GP improvement?

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The question of whether Primary Care Networks (PCNs) are to replace individual practices as the focus for improvement in general practice is an important one.  If the answer is yes, it potentially represents a direction of travel whereby the focus on the individual practice could be significantly reduced, and (conversely) the opportunities for practices through PCNs could increase way beyond the level set out in the contract.

I asked Robert Varnam, Head of General Practice Development at NHS England, in a recent interview for the General Practice podcast whether PCNs are the new unit of GP improvement.  His response was that while there is a focus on the unique and individual needs of each practice at present, we are in a period of “transition” from practices to PCNs, and are moving increasingly towards working with practices as a group within their individual networks.  The rationale is that when practices collaborate they can generate more ideas more quickly, they can build shared resources that prevent things being done multiple times (e.g. training, directories of service etc) and networks create a route to accessing resources like new roles, that for some practices have been out of reach while working on their own.

Within such a transition, how will the focus on the specific needs of the individual practice be maintained?  This responsibility is likely to fall to the PCN itself.  The ‘system’ will support the PCN, and it will be the role of the PCN to support its member practices.

The question then for the PCN is how it intends to support its member practices.  There are two potential routes open.  One is to use the PCN as an exercise in collaborative improvement for its member practices (and the populations they serve).  The second is to treat the PCN as a bureaucratic hurdle to be overcome to secure resources for member practices.

It is the role of the practices in each PCN to decide what the right balance is for them, and which of these routes they want to go down.   I suspect the assumption made in some STPs and in some quarters nationally that all practices are opting for the former rather than the latter of these two routes is unlikely to be right.  The differing attitude of PCNs to the £1.50 running costs is illustrative of this, as some PCNs are spending as little as possible to maximise the resources that remain for practices, and some could have easily already spent the £1.50 twice over as they embark on a series of different local change initiatives.

Underneath this choice is a question each practice needs to grapple with on its own, which is in light of this overall national direction and given the challenges we face how will we make improvements to our practice?  Will we do it on our own, using the (increasingly limited) resources that will be available?  Or will we do it through the PCN, using the opportunities that brings?  Is it to be done at a practice level whenever we can, and a PCN level when we have to?  Or PCN level whenever we can, and practice level only when we have to?  The mindset here is key.

The PCN route brings resources such as new staff and new investment, as well as the opportunity to make bigger, bolder, more impactful changes.  But as ever there is a trade-off, as individual practice autonomy is reduced, there is less individual control on changes happening across a larger group of practices.  And, inevitably, the more GPs that are involved, the more difficult introducing any change can be.

So far PCNs have been largely about set-up and getting the fundamentals in place, and the opportunities for improvement have not yet been widely exploited.  What remains to be seen is whether practices will choose to use PCNs as a collaborative opportunity to create a general practice that can thrive into the future, or whether PCNs end up as a largely administrative exercise that serve a wider purpose but do not really help core general practice.  PCNs may be the perceived unit of general practice improvement going forward, but ultimately it is up to practices to decide whether this is a route they are prepared to travel down.

2
oct
0

Why PCNs are difficult – Part 2

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In the world of start-ups, the mantra is that any new idea has to solve a problem. Google solved the problem of finding things on the internet, while Amazon solved the problem of buying things on the internet. But start-ups that begin with a solution and search for a problem to solve are the ones that find life much more difficult.

Google Glass is a classic example. It failed because the creators neglected to define what problems it was solving for its users. There was not even a consensus among the creators about what the core use of Google Glass was. One group argued it could be worn all day as a fashionable device while another thought it should be worn for specific utilitarian functions. They assumed the product would sell itself, and that its hype would be enough to appeal to everyone. But in the end, Google Glass did not provide enough advancement for users compared to older technologies (phones), making the product a useless supplement to their daily lives.

There are some interesting parallels between Google Glass and Primary Care Networks (PCNs). There is not a clear consensus as to the core purpose of PCNs. The wider system wants them to be a mechanism through which general practice is “integrated” with the rest of the system, and the GPC want them to be a mechanism for greater investment into general practice. There is an assumption that by channelling resources through PCNs it will make them successful. But in the end, if PCNs do not make a big enough difference to member practices, success is by no means guaranteed.

PCNs need to work hard to avoid being a solution looking for a problem. Because success depends so heavily upon the engagement and participation of member GPs and practices, they have to define themselves early on as the solution to the twin problems of workload and financial viability. These are the problems in general practice that need to be solved, and working at scale, introducing new roles, and working with the rest of the system are proven solutions, and all (potentially) encapsulated by PCNs.

But the reason PCNs are so difficult is that change is not that straightforward. You can’t start with the solution (PCNs) and expect practices to buy in straight away. Changes succeed or fail as a result of understanding the problem, and building confidence that the solution offered can make a difference. If operating at scale was that easy, we wouldn’t still have 7,000 individual GP practices. If introducing new roles was that easy, they would be much more widespread across practices. If working with the rest of the system was that easy, we would have more than a handful of examples of practices working in partnership with acute and community trusts.

The challenge, then, that largely sits with the new PCN Clinical Directors, is to do the work to understand the specific problems facing local practices, and to convince the local GPs that by working with and through the PCN these problems can be tackled. Without this, PCNs risk being a solution looking for a problem, and ending up the same way as Google Glass.

25
sep
0

Which is better? A Federation or a Primary Care Network?

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The rapid emergence of Primary Care Networks (PCNs) has led practices in many areas to consider the question of whether they are better off as part of a federation, or whether it would simply be better to go it alone as a PCN. So which is better, a PCN or a federation?

What criteria do you use to make this decision? Generally, it comes down to a “what have the Romans ever done for us” consideration. Has the federation/PCN had a beneficial impact on practices? Or does it feel like an entity ploughing its own furrow without really impacting on member practices?

The answers to these questions will vary locally. But the opportunity federations and PCNs can provide for member practices is clear. Federations can provide an organisational structure that PCNs (that are not legal entities) can harness to employ staff, manage risk, and take away any personal or practice liabilities. They can deliver benefits of operating at a greater scale than PCNs, such as attracting higher calibre staff, establishing central functions (such as finance and human resources), and reducing costs through better purchasing power as well as attracting funding for general practice. They operate at a scale where they can build and maintain organisational relationships with all of the local health and social care organisations in way that an individual PCN cannot hope to. General practice itself can have a much stronger voice in the system if the federation is speaking on behalf of all practices, where six PCNs wanting six different things can quickly dilute the collective voice of the profession.

A PCN on the other hand can have a much closer and more intimate relationship with its member practices. It can take time to fully understand the individual challenges each of its practices is facing and take tailored action to support them. It can be nimble and change direction quickly. If the focus needs to change from one challenge to something more pressing it can be reactive and responsive. Each practice can be part of the decision making, and understand exactly what has been decided and why. There can be a transparency about funding, use of resources, and exactly where everything is going. They can make change happen at a local level in a way federations could never hope to, because of the relationships they have in place.

For those of you with longer memories, you may remember back in the days when CCGs were being formed one of the key questions was – what is the right size of the CCG? Should they be small and closer to practices, or should they be large and able to consolidate resources and the available funding to maximise the impact the CCGs could have? In the end both arguments were right: the smaller CCGs didn’t have the resources, influence and financial stability needed to be effective, and the larger CCGs quickly became distant from practices.

The lesson here is that you need both. You need to be large to be effective, and you need to be small to remain relevant to local practices and local populations. The incredible opportunity that general practice has in areas which have federations in place is to have both: they can use the federation to achieve all the benefits that size requires, and the PCN to maintain the localism and energy to drive locally relevant change.

The difficult question, then, is not whether a federation or a PCN is better, but how to bring federations and PCNs together in a way that maintains the trust and confidence of local practices, and allows the two to work effectively together for the benefit of all.

18
sep
0

Three top tips for PCN development plans

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The development funding available for Primary Care Networks (PCNs) is a tremendous opportunity. But how to make best use of the money? How should PCNs focus their development plans to ensure the money has the maximum impact? This week I consider three ways PCNs can ensure they make the most of the new money.

1.Get Capacity

The one thing that can accelerate the development of a new entity like a PCN more than anything else is capacity. It is virtually impossible for new PCN Clinical Directors to have the time to do everything that is needed to be done in the limited number of sessions they have available. They need someone to be enacting the decisions made, delivering on what has been agreed, and doing the work required to turn ideas into real change. One of the biggest frustrations of the new PCN Clinical Directors is lack of time, and additional capacity in the form of a project manager is the best way of overcoming this.

While some PCNs may be forward thinking enough to invest some of their (recurrent) £1.50 in project management support, many are reluctant to commit what is effectively practice money so quickly. The development fund gives PCNs the opportunity to try a project manager on a fixed-term basis, and then down the line if they find it is a worthwhile investment they can consider making the post permanent using the £1.50.

2.Focus on Delivery

There is something intangible about “development”. But for any new entity (and PCNs are no different) success is dependent upon their ability to deliver. Attending the right meetings, saying the right things to the right people, and learning about how the system works are all well and good, but ultimately if the PCN is not able to deliver anything, it will not be a success. The most important part of development is learning how to deliver.

The best way to learn how to deliver is to deliver something! Don’t think about development as something that is done before you start delivering. Think of it as what you learn while you are trying to deliver. So in the PCN development plan identify what you want to deliver, and make sure you include the resources necessary to make it happen.

3.Create Benefits for Practices

The most important stakeholders in PCNs are the member practices. If the member practices believe in the PCN and its ability to make a difference, then the PCN is much more likely to be successful. Conversely, if practices are working to keep the PCN at arms-length, meaningful change is going to be very difficult to realise.

It is therefore important to demonstrate as early as possible to practices that working together can create significant benefits for the practices and their patients. This is particularly important if the experience to date has been a set of painful meetings to create a network agreement, and then pressure to deliver extended hours. It is perfectly reasonable for the development plan to include work that will not only deliver benefit for member practices, but also include the resources to achieve it.

 

11
sep
0

Why PCNs are difficult – Part 1

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Change is difficult. Changing behaviour is even more difficult. Persuading other people to change their behaviour is even more difficult still. Which is why PCNs are difficult.

The really difficult part of PCNs is that the main benefits come as a result of GPs changing how they work. PCNs have all recently been through the trials of working out how between them they are to cover the extended hours requirements that now fall on the network. The (relatively) easy route is to say everyone has to do their bit. The impact of this is that practices who were choosing not to do it, now have to “choose” to do it. So the impact of the Primary Care Network (so far) on those practices is that they are having to do more work.

At the other end of the spectrum, practices in a PCN work out how they can see each other’s patients. They create a “hub” to carry out extended hours on behalf of all the practices. They expand the remit of the hub beyond extended hours, and into seeing all the on the day demand from the practices across the network. The team seeing the on the day demand is multidisciplinary, led by a GP. The impact on the GPs in the PCN is that they have more time for routine appointments, and they experience some relief from the constant pressure of the daily demand.

The first option does not require GPs to change their clinical practice. They simply have to do more of the same in order to comply with the requirements of the PCN. In that sense it is “easy”, and is why many PCNs have gone down this route.

The second option requires a whole raft of changes. It means all the practices have to agree to the new way of working. It means practices have to trust their patients to be seen by clinicians from other practices. It means the way each practice delivers continuity of care has to change. It means the management of the new urgent care team needs to be agreed. It means when things go wrong practices have to work together to solve the problems as they arise. It requires strong leadership, trust between the practices and a willingness to make changes together.

In summary, it is an extremely difficult option to put into practice, and why most PCNs would have discounted it (or anything similarly disruptive) as an option without much consideration. The opportunity for significant gains is there, but the journey to achieve them is so difficult that they are not realised.

This, incidentally, is the reason many mergers have not made life any better for the GPs involved. Instead of delivering “economies of scale” they have simply led to twice the problems and twice the number of people to engage when any decision needs to be made. In the same way that mergers are not a solution in themselves, but rather create the opportunity for improvement, so PCNs are not a solution for general practice in themselves, but rather create an opportunity for things to be better.

PCNs are an opportunity, but an opportunity that is difficult for practices to exploit. PCNs are difficult because change is difficult, and for PCNs to make a real difference to general practice, real changes need to be made: changes to the way practices work together; changes to the way individual practices in the PCN operate; and changes to the way individual GPs (including those that may not want to make the change) operate.

4
sep
0

Making the most of PCN development support

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The good news is that £43.5m has been released nationally to support PCN development. This is new money for PCNs, and according to the guidance is “a floor not a ceiling”. The money can only be used for PCN development or PCN Clinical Director (CD) development. “Around 10% of the funds are intended for CD specific development” (expected to be £3,000 – £4,000 per CD).

The process for accessing the funding is relatively straightforward. PCNs are to self-assess their current needs in September, and determine how they want to develop in a support plan. The PCN Maturity Matrix (here) or local version thereof is to be used for this self-assessment. PCNs are also to identify “a specific service improvement priority to focus on as a means for closer collaboration”.

6 development support “domains” have been identified that the guidance suggests PCNs will want to access as they work on their agreed priority: PCN set-up and support, organisational development and change, leadership development and support, supporting collaborative working (MDTs), population health management, and social prescribing and asset based community development.

The PCN identified support plan has to be agreed by “ICSs/STPs, places, CCGs, PCN CDs and other system partners”. In practice for the majority of places this means the CCG and the PCN CD have to agree it. The support is to be mobilised in October. Then “systems and CCGs support PCNs to review progress against PCN priorities and self-assessment” once the support is in place through to March.

There is a parallel process for systems to work with the new PCN CDs to identify their individual and collective development needs and develop tailored plans with support requirements. Once that support has commenced, “with support from systems, PCN CDs review progress against priorities. Areas for additional support identified, revised development plan produced”.

So there is a huge opportunity for PCNs to access a significant chunk of funding that can support the member practices and their work together. There is a risk that accessing the funding becomes the mechanism by which the system exerts management control (i.e. the PCN cannot have the funding unless it is operating in the way in which the system wants it to), and the joint review of progress between the PCN CDs and the system become performance management meetings. But this risk can be mitigated, and the amount of development funding mean it is worth jumping through a few hoops to access it. The key is keeping control of the agenda (which I have written about previously) – if the PCN is clear what it wants to achieve, then this whole process can be worked as an enabler for that.

My main advice to PCNs thinking about their development needs is to differentiate between the internal and external needs. By internal needs, I mean the needs of the member practices, the strength of the relationships between the member practices, and the ability of the practices to work effectively together and deliver services. By external needs, I mean the ability of the PCN to work collaboratively with community services and other teams, to understand the local population health needs, and to be and active partner within the wider STP/ICS system.

I think it is important to prioritise the internal needs first. If practices cannot work together, support each other, agree on priorities, and make changes to delivery across practices, the PCN is very unlikely to be successful. This joint working between the practices is the bedrock of PCN success. All other things will follow if this is in place. So my advice is to prioritise working on the internal needs first, even if both practices (because it can be difficult and threatening) and the system (because they want to widen the focus of PCNs) want more of the initial energy focussed on the external needs.

28
aug
0

What is a Primary Care Network?

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What is a Primary Care Network? Well? What would you say? It is a question that should be simple to answer, but in reality is not. According to the NHS England website, “They consist of groups of general practices working together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations”. Is that what you were going to say? I didn’t think so…

The NHS England definition feels more like an ambition than a definition. Technically, today, a Primary Care Network is a group of GP practices who have signed up to the Network Contract DES, and who as a result have a Clinical Director and a network agreement in place between the practices. And, as the Network Contract DES Specification states, “There is no requirement for the Network Agreement that is signed by 30 June 2019 to include collaboration between practices and other providers, but this will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated to reflect the new Network Contract DES specification.”

Why have GP practices joined primary care networks? Of course for some it is the opportunity to deliver coordinated, integrated care for the local population, but for most it is because access to much of the financial and workforce resources in the new GP contract is dependent on joining. There is an expectation that up to 40% of the additional funding for general practice will come through the new networks, and as the GPC’s initial press release about the new contract said, “Support and funding for Primary Care Networks mean practices can work together, led by a single GP, and employ additional staff to provide a range of services in the local area, ensuring patients have ready access to the right healthcare professional, and helping reduce workload pressures on GPs.”

So we are in this strange limbo position whereby the NHS has introduced Primary Care Networks and created a rhetoric around them that they are to do one thing (co-ordinate and integrate care for local populations), but an establishment of them where the on-the-ground reality is about GP practices working together to secure the investment and resources they need to survive.

This, inevitably, is leading to confusion. The wider system is somewhat bamboozled by Primary Care Networks and the conflicting messages about them, and as a result has no idea what to make of them. “PCN” is being added to the list of acronyms such as QOF, PMS, GMS that make general practice so inaccessible to outsiders. Even practices themselves are not sure whether to keep the PCN at arms-length, and insist that PCN services are kept distinct from the services provided by individual practices, or to embrace the opportunity for cost-saving, income generation and workforce development that PCNs could potentially provide.

But in the midst of this wider confusion there is huge opportunity for practices. If practices can maintain clarity on exactly what a PCN is (as defined by their contract), keeping in mind that the contractual requirements will change and evolve, it actually puts them in a strong position. They can focus on maximising the opportunities of PCNs for their practices for now, and on ensuring that as the system asks for more from PCNs (as it inevitably will) that appropriate funding follows.

21
aug
0

Primary Care Networks: Who sets the agenda?

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It has been a challenging start for Primary Care Networks (PCNs). From first settling the membership and getting the network agreement signed, to then immediately having to tackle any half day closure issues and practices who were not providing extended hours, it is fair to say the journey so far has not been easy. But where does the focus now lie for PCNs?

The risk for PCNs is that they continue to be recipients of an agenda and a timetable set by others. Now PCNs are in place, there are a plethora of organisations and individuals keen to meet them and talk about their work and their programme and how the PCN can support it. The number of meeting requests for the new PCN CDs is growing, and will doubtless accelerate once the holidays are over and September arrives.

PCNs are different from CCGs and other NHS organisations, in that they are not statutory bodies. The NHS hierarchy has no formal control over them. Born out of the GP contract, they are contractual constructs and as such are independent contractors in the same way that GP practices are. If it is not in the contract, the PCN can choose not to do it.

There is a power in this position. Clearly it is going to be in the interest of the PCN to build constructive relationships with other organisations (even if the primary motivation is to make delivering the future contractual requirements easier!), and to take actions to support the local population. But this is different to letting others set the agenda for your PCN, in terms of what it is trying to do and what it spends its time discussing and working on.

The establishment of a PCN is an exercise in change management for general practice. Changes succeed or fail depending on the extent to which the problem the change is trying to solve is clear, the extent to which those involved in the change are bought in to solving the identified problem together, and the ability to show progress over time towards solving the problem (I would strongly recommend you take half an hour to read this book if you haven’t already).

This means to be successful PCNs need to exist not because the contract mandates that they do, but as an enabler to solving the problem(s) the practices have identified. It is critical PCN practices spend time agreeing exactly how they want to maximise the benefit of the new PCN, whether that is the outcomes for the local population, the financial sustainability of the member practices, the workload of the member GP partners, or whatever the key local challenges are.

Once this is clear, setting the agenda is much more straightforward. The PCN will prioritise anything that supports delivery of its aim, and de-prioritise anything that does not. Control of the agenda comes from the PCN itself, not from outside. If progress is monitored by the use of some agreed regular measurements, this focus will remain in place as the months progress.

But without a clear purpose, PCNs run the risk that their agenda will be set by others, that they will achieve very little that makes a difference locally, and that any initial enthusiasm and support from practices will quickly wane. As the contractual requirements lessen for the remainder of the year, and as PCN development monies emerge, if you have not done so already now is the time for member practices to establish and agree what they want the PCN to achieve, and then to make sure it controls the agenda and how its precious time is used to ensuring that goal is delivered.

 

14
aug
0

Should PCNs have a national voice?

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There was an interesting recent debate on one of the national WhatsApp groups about whether there is a role for an independent national PCN voice. Opinion was divided, with strong proponents both for and against.

The argument for goes along the lines that PCNs are something new (with a new cadre of PCN Clinical Directors) doing something different and more inclusive than general practice, and hence need to be represented at a national level in a different way to the GPC/how core general practice is represented.

I think there are two main reasons why this is not a good idea. First, it will weaken the national voice of general practice. General practice remains in crisis, despite the new contract and the formation of PCNs. It is critical that general practice retains a strong national voice. It currently has this through the GPC. If a separate voice for PCNs develops, it risks enabling the government, NHS England and national bodies to bypass the GPC, and push initiatives and new ways of working onto general practice via the PCN route. The greater dependence general practice has on PCN funding, the greater this risk becomes.

Second, it could limit local PCN flexibility. There are people working hard to try and enable the development of PCNs to be determined at a local level. One of the key strengths of PCNs is as local network enablers, bringing general practice together with a wide range of local stakeholders for the betterment of local outcomes. Each place is different, and will need different strategies and ways of working, and (more importantly) will want to control how this happens for itself. The old mentality of being dictated to from on-high needs to be replaced with a vibrant local determinism, a shift far less likely to happen if a national PCN representative body exists.

PCNs do, however, need a strong voice within their local integrated care system (ICS). Part of the PCN Clinical Director role is to represent the PCN within the local ICS, and how effectively this happens may determine whether there is any overall shift of resources (and workload) from secondary to primary care, and whether the system invests in primary care.

The key to this voice being strong is for general practice to ensure it presents a united front locally. If general practice is represented by a federation, the LMC and PCNs, none of whom can agree on what they want or how they want it, the voice is divided and the overall voice is diluted. Ultimately this internal division will end up in less resource being shifted to primary care.

The desire for a separate PCN voice comes from a sense of some GPs and practices not feeling represented. The solution, however, is not to create a separate voice for them, but to work hard to establish an inclusive, strong, unified voice for general practice, and to work to overcome the often historic barriers and disputes that exist within general practice for the benefit of all.

Here at Ockham Healthcare we have produced a free guide for PCNs which outlines 10 practical steps for PCNs to establish a powerful voice. It is free for subscribers – to subscribe simply click here. A unified PCN voice at a system level, and a single general practice voice at a national level, will maximise the overall impact of general practice on the system, and increase its chances of emerging from its current challenges.

7
aug
2

The danger of the PCN “maturity matrix”

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How will you know if your PCN is “mature”? What is maturity of a PCN, and who is to decide when you have reached it?

There is a danger that NHS management speak (I think it is fair to categorise “PCN maturity matrix” in this way!) can generate a life of its own. The PCN guidance suggests a national PCN maturity matrix will be produced (which was due at the end of July, and so should appear any day now). The PCN frequently asked questions says that “all systems should use the provided maturity matrix in the first instance to assist with assessing the relative maturity of networks”.

This response inevitably gave rise to the next question, “Will the PCN maturity matrix be used for performance management?”, and we are assured that, “the maturity matrix is not an assurance vehicle for PCN performance”. However, it does seem that creating a PCN development plan based on an assessment against this matrix will be a required gateway for accessing PCN development monies.

While there is clearly a value in laying out for nascent PCNs what “good” looks like, the danger of a national PCN maturity matrix is that it could impose requirements or expectations upon a PCN beyond those set in the national contract. It could start to impinge not just on what PCNs have to do, but how they have to do it. There is a fine line between a national framework (and NHS England has pushed back on any attempts by local areas to create their own framework) that helps PCNs to develop, and one the determines how they should operate.

Rather than let a national team decide what maturity looks like for your PCN, it may be better for the PCN itself to determine what maturity looks like. A PCN that decides for itself where it is going and how it will develop will be likely to progress more quickly, as it will retain ownership of its future. Equally, if a national framework is used to shift autonomy away from member practices and assert top down control on how PCNs are to operate, progress is likely to be laboured.

So what is maturity for your PCN? I would argue it is essentially framed around the ability to deliver:

  • The ability of the PCN to deliver across the member practices (see last week’s blog for the importance of the relationships between the practices, an area unlikely to be given prominence in the national maturity matrix)
  • The ability of the PCN to support member practices who struggle with delivery, and to support the delivery of core general practice
  • The ability to remove blocks to delivery as they occur, such as resolving disputes between member practices
  • The ability of the PCN to build productive relationships with system partners to enable effective delivery
  • Having the infrastructure in place to enable effective delivery, such as data sharing, access to information, ability to attract, employ and retain staff, project management etc.
  • The ability to access good ideas, new ways of working, solutions to challenges and support when needed from both inside and outside of the PCN to enable delivery
  • Having effective leadership in place that can make delivery happen

Your PCN will inevitably have its own view on what its maturity looks like. The key is a good PCN is not necessarily one that is assessed as “mature” against all elements of a nationally set maturity matrix, but one that can turn ideas into actions and into tangible results, and is able to make the biggest possible difference for its practices and its patients.

Clearly it is worth jumping through a few hoops to access what is a significant amount of PCN development money. But don’t let the process determine how you will develop. Make that decision for yourselves.

31
jul
0

The relationship between a practice and a PCN

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As a GP practice, how do you think of your PCN?  Do you see it as a joint initiative between you and your fellow practices to work together to make life better for each other and for your patients? Or do you see it as something you have to do because the GP contract/CCG/government have decreed it?

When you think of the work that does and will take place through the PCN, do you see it as practice work done jointly with the other PCN practices? Or is it “PCN work”, separate from the work you do in the practice?

How the relationship with the PCN “feels” to the member practices is crucial.  If it feels like the PCN sits above the practices, in a hierarchical fashion (as depicted on the left below), there is going to be a perceived separation between the practices and the PCN.  The work of the PCN will feel separate from the “core” work of practices, and the PCN will run the risk of being a burden to practices both in terms of workload and finances.

If the PCN feels like it is the group of practices working together (as depicted on the right), then the opportunity of PCNs for practices is greater.  The work of the PCN will support and become part of the core work of practices, rather than operate separately from it.  The PCN work becomes the way the practices can improve their workload and their finances.

Even within one PCN the attitude towards it by member practices can vary.  You may have one practice viewing it as something separate, but another seeing it as integral to the practice and how it operates.  This point was brought home to me this week in a conversation I had with Paul Deffley from Practice Unbound (watch out for this episode of the General Practice podcast coming up in August).  He described a pharmacist operating across two practices.  It was the same pharmacist following exactly the same processes and seeing exactly the same types of patient.

The reaction to the pharmacist by the two practices was completely different.  One practice quickly got to the place where they couldn’t imagine how they ever managed without a pharmacist before, and thought the impact on the GPs and on the practice had been enormous.  The other practice was far less enamoured, and if anything thought the pharmacist had created additional work for the GPs.  The main difference was the first practice had actively engaged with the pharmacist, invited them to team meetings, and made them part of the practice “family”, whereas the other practice had never embraced the pharmacist in the same way.

If a practice welcomes and takes on the PCN initiatives as part of the way they are now working, the impact for the individual practice, and the for the PCN overall is likely to be considerable.  If a practice keeps its focus on what it can control, and keeps the PCN work at arm’s length, the impact will be far less.

The implications of this are huge.  It impacts the extent PCNs are able to make changes to meet the needs of practices, and how effectively PCNs can support the sustainability of general practice.  It will directly affect the finances.  Practices would willingly pay a third of the funding for new services that they want, if the “centre” is chipping in 70%.  Subsidising an arms-length PCN initiative for the same amount is an entirely different matter.

It is not the existence of PCNs that is important, but how they operate.  This will vary considerably across the country.  For all the talk about PCN plans, maturity matrices, and development programmes, my number one focus right now for making a PCN successful would be on getting the relationship between the practices and the PCN right.

17
jul
0

The Top Ten Most Popular General Practice Podcasts of All Time!

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While the General Practice podcast is having a few week’s holiday (it will be back on the 29th July), it is a good time to catch up on some of the episodes you may have missed.  The podcast started in 2016, and there are now over 170 episodes, so choosing the best ones might be a challenge!  To help you I’ve identified the 10 most downloaded episodes, as they may be a good place to start. Here, in traditional reverse order, are…

  1. Marie-Anne Essam – Social Prescribing and Link Workers

In this episode, I spoke to Marie-Anne Essam a GP in Herts Valley and an enthusiastic ambassador for social prescribing. She explained what it is and told a powerful story about a patient of hers which amply illustrated the value of social prescription. She also talked about the specific role of link workers including their salary, their competences and their likely backgrounds.

  1. Riaz Jetha – The new Primary Care Network DES

In the days immediately following the publication of the new network DES special guest Dr Riaz Jetha and I discussed the newly released specification. We looked at the nature of the network agreement, the role of federations, how clinical leaders were to be recruited, population size, funding and much more.

  1. Neha Shah and Colin Haw – The practical implications of establishing PCNs

In this episode I was joined by Neha Shah, a Legal Director from Capsticks and Accountant Colin Haw from BHP Chartered Accountants.  They discussed some of the legal, financial and governance issues facing general practice as it began to establish Primary Care Networks. Specifically they considered how networks would be hosted and the implications for liability, choices around the organisational form, employment contracts, pensions and VAT.

  1. Ben Gowland – The new GP contract

In this episode the tables were turned with me in the hot seat detailing the importance of the new GP contract. I explained, in the week after the publication of the new GP contract, why it is a huge opportunity and gave me optimism for the future. I described the way that the additional £2.8bn attached to the contract was expected to flow, how primary care networks were to be developed and how they would be staffed. I also gave some practical advice to practices about what they should be doing then, in preparation for the year ahead.

  1. Ceinwen Mannall – Education for clinical pharmacists in general practice

In this episode I spoke to Ceinwen Mannall, who is the national lead for Clinical Pharmacists in General Practice education at the Centre for Postgraduate Pharmacy Education (CPPE).  She told me about the training available to pharmacists moving into general practice, the impact and value that pharmacists have and tips for practices thinking of employing a clinical pharmacist.

  1. Tom Howseman – Better managing demand through pre-triage protocols

Tom Howseman is a GP Partner in a large urban practice in Northampton. When their complement of GP partners fell from twelve to six due to retirements and they couldn’t recruit they decided to adopt a more multi-disciplinary approach. Over the last two years they have introduced and refined a system of pre-triage protocols which enable reception staff to collect information from patients presenting on the day which is then helpful to the pre-triage clinicians in directing those patients to the appropriate member of the emergency care team. 20,000 additional appointments have been created through this system and in this episode Tom explained how they have done it.

  1. Rachel Morris – GP stress, burnout and resilience

Rachel Morris is a GP, an executive coach and presenter with Red Whale; producers of the famous GP Update. In this episode she looked at GP resilience; what it is and how can you acquire it. She considered the causes of stress and burnout and pointed to a range of useful resources GPs can use to develop their personal resilience.

  1. Nikki Kanani – The new GP Contract – Part 1

My special guest for two weeks in February/March this year was Dr Nikki Kanani, one of the chief architects of the new GP contract. Nikki is a GP in south-east London and is currently Director of Primary Care for NHS England. This is the first of two discussions with Nikki in the Top Ten and in this part, she explained the role of primary care networks in general practice and looked in detail at the funding behind the new contract. She explained how the money would be delivered and for what it would be made available including 20,000 new staff, support for clinical leadership and Investment in innovation.

  1. Nikki Kanani – The new GP Contract – Part 2

In this second part of the interview with Dr Nikki Kanani she addressed the concerns of podcast listeners about primary care networks including population size, hosting of the networks and the role of federations. She looked at how clinical leaders should be identified and focused in detail on the timetable from March 2019 onwards and what practices should be doing at that time to guarantee success.

  1. Rachel Morris – Developing GP leaders

Top of the pile, and more popular than even Nikki Kanani, sees the second entry for Dr Rachel Morris.  In this podcast Rachel described two courses that Red Whale were running aimed at developing leadership skills in primary care leaders. The first is Lead. Manage. Thrive! – a very popular one day course in management skills for GPs. The second wass a new course on Working At Scale. Rachel explained how and why the programmes were developed, who the training is aimed at and what the courses cover.

So that’s the current Top Ten. Don’t forget, if you’d like to see something featured in a future episode of the General Practice Podcast or you’ve got a story to tell yourself, just email me at ben@ockham.healthcare or DM me on Twitter @benxgowland and we’ll do the rest.

10
jul
0

Guest Blog – Nick Sharples – PCNs and Social Prescribers

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With the vast majority of Practices now a part of a Primary Care Network, and a week into the formal ‘Go Live’ date for PCNs to start operating, PCN Clinical Directors and their teams are starting to consider recruiting the Social Prescribers for whom the NHS are providing full funding in the current financial year. Now is perhaps therefore an opportune time to review the ways in which PCNs can best recruit, train and introduce Social Prescribing to their new organisations.

Our engagement with PCNs regarding training for Social Prescribers has identified a number of different models currently being considered by PCNs. Perhaps the most innovative approach is to realise that the opportunity is significantly greater than simply recruiting an additional member of staff. These PCNs are already examining ways in which the recruitment of the new Social Prescriber can herald the introduction of a Social Prescribing culture and the provision of a comprehensive Social Prescribing Service throughout the PCN. This can be achieved by leveraging the people skills of the health professionals already working within PCN Practices and recruiting suitable volunteers from the patient community to support the Social Prescriber, who sits at the heart of the new Social Prescribing Service.

Introducing a Sustainable and Comprehensive Social Prescribing Service across the PCN

It may seem a little counter intuitive, if not naïve, to believe that one can create a sustainable and comprehensive SP service with just a single Link Worker to support potentially 50,000 patients. But with imagination and determination it is not impossible. The key is in being prepared to engage and upskill existing staff and leverage them to support the primary Social Prescriber, and in doing so to help the new funded Social Prescriber be as effective in their role as possible.

Practice Social Prescribing Champions

With the average PCN in England likely to comprise between 3 – 6 Practices (based on an average list size of 8,490 in Dec 2018), forward thinking PCNs are seeking to train up not just the primary Social prescriber but a suitable volunteer member of staff with the right people skills from each of the PCN practices. These Social Prescribing Champions in each Practice will facilitate and smooth the referral process to the primary Social Prescriber, actively recruit volunteers from their patient communities to assist the Social Prescribing Service and will be trained and able to stand in for the primary Social Prescriber when he or she is on holiday or off sick.

Where appointment capacity becomes a problem for the primary Social Prescriber, as experience with the introduction of other allied health professionals suggests it will do, these Practice Champions, trained to the same level as the primary Social Prescriber, can undertake their own Social Prescribing, working in their own Practice and with their own patients to alleviate waiting times for the primary Social Prescriber. This may not be practical in every Practice and will depend on the clinical priorities determined by the GPs, but some are starting with a half day a week of Prescribing from their own trained Champion and building up as appropriate. However, if started, this needs to become a long-term commitment with a long notice period, as continuity of Link Worker is fundamental to building the trust and relationship with the patient.

Volunteers

There is much emerging evidence that using volunteers alongside trained Social Prescribers can significantly enhance the scope and reach of a scheme. Volunteers can provide emotional and practical support to service users and have in some cases been further trained as link workers to provide facilitated referrals to some of the community groups within the local area. They come from a wide range of backgrounds; some may be recruited from patients who have been referred to the service and wish to volunteer as part of their social prescription; others may come from the Patient Participation Group and yet more may be locally recruited volunteers with multiple skills and experience of life who wish to offer something back to the community. Recruitment of a cadre of volunteers at PCN Practices will significantly increase the overall effectiveness of the Social Prescribing service.

A Potential Structure Suitable for a PCN to Establish a Comprehensive Social Prescribing Service (Click image to enlarge)

 

The Primary Social Prescriber – PCN Controlled or Aligned with Existing Local Scheme?

Given the challenges of expecting a single, unsupported Link Worker to make a significant difference in a patient community of up to 50,000, NHS(E) and the Social Prescribing Network have both suggested that the most effective way of managing new PCN Link Workers is to closely align them to an existing Social Prescribing Scheme in the area. This can range from close collaboration and sharing of administration, resources and operating protocols where appropriate, through to fully outsourcing the employment and management of the Social Prescriber to a local CVS scheme.

For both outsourcing the role and for close collaboration, the choice of host CVS based scheme is crucial. Ideally it should be already working with and taking referrals from Primary Care in some respect so that the working practices and administrative processes are similar. For example, whilst a local Social Housing based Social Prescribing scheme might be delivering great results, it is unlikely to be working closely with GP Practices in the manner that will be expected of a PCN based Social Prescriber. The desired synergies from aligning the PCN Social Prescriber with such a scheme are therefore unlikely to be realised.

Recruiting the Social Prescriber – Upskill or Recruit from Outside?

PCNs are currently considering whether to upskill an existing member of staff as a Social Prescriber or recruit from outside. Recruiting skilled and experienced Social Prescribers from existing schemes in the voluntary sector is a possibility, but this does nothing to expand overall Social Prescribing capacity and is likely to lead to ill feeling between Primary Care and existing Social Prescribing schemes. Additionally, in large urban areas with many PCNs seeking to recruit Social Prescribers, the availability of external, currently unemployed candidates is likely to be quickly exhausted.

Up skilling of existing Practice staff has many benefits; they are already known to GPs within the Practice/PCN, they will be familiar with procedures in the Practice and, if their PCN has undertaken Active Signposting training for their Reception teams, they will have a good understanding of the available services and community groups operating in the area. In short, after suitable training in the specific skills needed by a Social Prescriber, they are more likely to be ready to hit the ground running.

The only real prerequisite for upskilling an existing member of staff is that they fulfil the person specification of a Social Prescriber. These soft people skills are inherent in those who make the best Social Prescribers, and it is no surprise that many come to Social Prescribing from the caring professions. These soft people skills include a natural desire to help people and give them time, the ability to listen, empathy, patience, excellent communication and organisation skills, the ability to inspire trust and confidence, and the flexibility, resilience and initiative to work on their own with minimal direction. Nurses, HCAs, some Receptionists, Social workers and voluntary workers often make good Link Workers.

Training the New Social Prescriber and Practice Champions

If recruited directly from a local CVS based scheme working closely with Primary Care, the new Social Prescriber is unlikely to need much additional training. In all other circumstances however, the newly recruited Prescriber will require upskilling in the specific skills used by Social Prescribers. These include Active Listening, Motivational Interviewing, Health Coaching, preparing Care Plans and managing the administrative processes required of the role so that they align with those of the PCN.

Motivational Interviewing skills are particularly important in a Primary Care setting, where the percentage of referred patients who are at the pre-contemplation stage of the change cycle tends to be higher than for service users in CVS based schemes.

If adopting the PCN Social Prescribing service structure suggested above, the training will also need to encompass the Practice Social Prescribing Champions who, by definition, are unlikely to possess any existing Social Prescribing skills. Training the new primary Social Prescriber alongside the volunteer Practice Champions is a wholly positive approach and should be considered the default.    It establishes the supportive network and close personal and professional relationships needed for the Social Prescribing service to operate effectively across the PCN.

If looking for external training support, PCNs would be advised to retain a training organisation, such as DNA Insight, who will train the PCN’s Social Prescribers as a single group and who will customise the training to suit the specific needs and operating protocols of the PCN. Facilitated Active Learning Sets, such as those included in DNA Insight’s SocialPrescriberPlus™ programme, help the whole Social Prescribing team to build an enduring and close personal and professional network that can address challenges, identify and build on Best Practice, increase resilience within the team and meet the priorities set by the PCN Clinical Director and the Practices.

 Conclusion

In conclusion, the additional resource of a fully funded Social Prescriber to work across the PCN is a wholly positive development. On their own however, the challenge of supporting up to 50,000 patients is likely to be overwhelming and the expected benefits may not extend as deeply into the PCN Practices as had been hoped, especially once the Social Prescriber’s list has filled up and waiting times start to become unacceptable.

PCNs can however take an innovative approach to creating a sustainable and effective PCN-wide Social Prescribing Service – by training, utilising and empowering volunteer Practice Social Prescribing Champions to support the primary Social Prescriber. These Champions in turn recruit volunteers from the local/patient community with lived experience, some of whom may have benefited from the service, to provide practical assistance and support to the team, allowing the team to focus on delivering the best possible care to the greatest possible number of patients.

Other Social Prescribing models are of course available and are equally valid. The key outtake is that with initiative, ambition and innovation it is entirely possible to create a comprehensive Social Prescribing Service for a Primary Care Network, despite only having funding for a single Social Prescriber.

Useful Resources and Social Prescribing networks for PCNs and Link Workers

  • Twitter Social Prescribing Wednesday – @SocialPresHour – every other Wednesday and hosted/organised by Elemental
  • National Association of Link Workers www.connectlink.org Christiana Melam christiana@connectlink.org Professional body representing Social Prescribers/Link Workers with lots of useful resources for Link Workers and those employing them.****************

Nick Sharples is a Director of DNA Insight Ltd, a GP training consultancy specialising in providing advice and training in the High Impact Actions of the GP Forward View. The SocialPrescriberPlus™ programme is designed for new or existing Social Prescribers and Link Workers, whether GP-based or working in the community. For more information please call us on 0800 978 8323 or visit our website at dnainsight.co.uk

 

3
jul
0

What’s next for PCNs: The first 100 days…

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You made it! The 1st July has come and gone. The Primary Care Network is in place, the network agreement (largely) agreed and signed, you have a way forward on extended hours, and now you are “live”. But what is next for the PCN Clinical Director? Now you are officially on the payroll, it is time for the first 100 days.

Senior leaders often start new roles with a plan for their first 100 days. They are important because they set the tone for how things will be under your leadership. Here are seven things for new PCN Clinical Directors to consider making part of your 100-day plan.

1 Focus on relationships over delivery

The biggest mistake eager new leaders make is to have an almost zealous focus on delivering sweeping changes as early as possible in their tenure. They feel the need to prove themselves in the job by showing they can make change happen fast.

Practices are already nervous about the introduction of PCNs. A new PCN CD dictating to practices how things are going to be within a few weeks of taking on the role is going to make these feelings worse. Even if you are able to bulldoze through how the pharmacist is going to work in every practice, it will be at the cost of the trust, discretionary effort, and support that you will need going forward.

Instead, focus on listening to practices, understanding their different needs and challenges, and the concerns and hopes they have about PCNs. At the same time, identify the key leaders in the community, mental health and voluntary organisations in your area. Ask to meet them, don’t wait for them to approach you. A network of strong relationships will be essential for future success.

2 Ensure a communication system is in place

Communication across all members of a practice is not always great.   If practices don’t know what the PCN is up to, mistrust will grow. The challenge for PCNs is enabling two-way communication across a group of practices. Ask practices what they want – a WhatsApp group, a weekly email, or whatever will work locally, and how often, and put it in place. If you achieve nothing other than putting an effective communication system in place you can consider your first 100 days a success!

3 Agree what success for the PCN looks like

You may be one of the few PCNs who before they got lost in the details of network agreements and extended hours took time to agree what the PCN was for, what its purpose was, and how success would be measured. But if not, now is the time for the PCN CD to find out from practices what success for the PCN means to them, and then to play back something that all can relate to, so both you and the practices are clear on what exactly it is you are trying to do in your role as PCN CD.

4 Under-promise and over-deliver

This sounds simple, but all too often new leaders make grand promises early on to try and build support based on what they are going to do. They then spend the rest of their time having to explain why they haven’t lived up to their initial claims. It is far better to be cautious in what you say you can deliver, and to build trust as you go by not only consistently doing what you said you would do, but often times achieving considerably more.

5 Select the Meetings you attend carefully

The NHS has a nasty habit of taking new leaders and swamping them with more meetings than it is possible for any diary to bear. The challenge in your first 100 days is to keep as much control of your time as you can. You must decide the meetings you go to; do not let the system decide for you. Ultimately you will be judged on the success of your network, not on the number of meetings you have attended. If you are always in meetings you will have very little time for real delivery, and very little time for the visible presence you will need at practice level to build that all-important support and trust.

6 Find your personal support

Leadership is lonely. You will, however supportive practices are right now, have to make some very tough and most likely unpopular decisions. There will be times when choosing the right way forward will be hard, and you won’t know what to do. These are the times when you will need support; people you can turn to who you can trust and who will help you work things through. Better to find this support and have it in place before you need it, rather than wait until the inevitable crisis arises. It may be a trusted colleague in your PCN, the CD of a neighbouring PCN (you are all on the same side), or someone else whose experience and opinion you value. Make finding this support a priority for your first 100 days.

7 Deliver some small wins

Now remember you are not trying to deliver any sweeping changes in your first 100 days. By small win we are not talking about anything major. But if from your conversations with practices, listening to GPs, and meeting local stakeholders there are things you see that can be done that are relatively easy to implement (without generating antibodies!) then make them happen. No one is expecting a miracle straight away, and setting a tone of positive change can create momentum for the bigger challenges ahead.

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jun

Pack or pride – how should PCNs operate?

Posted by Blogs, The General Practice BlogNo Comments

“The strength of the pack is the wolf, and the strength of the wolf is the pack.” Rudyard Kipling

There is a nervousness amongst GP practices in the intertwining of their fates with those of other practices through PCNs.  The move to robust PCN network agreements can be about protecting the higher performing practices from being ‘dragged’ down by those who are not doing so well.

Equally, as GP practices choose the PCN they are to be part of, there is a tendency for competitiveness between PCNs to emerge.  Instinctively many GPs and practices want “their” PCN to be more successful than those around it, thus justifying the choice of the practice to join it in the first place.

Anyone working in general practice at present understands the pressure that the sector as a whole is under.  When faced with such an existential challenge, there is real value in working together to meet the challenges rather than shifting to a ‘survival of the fittest’ type attitude.

This is perfectly illustrated when considering the respective plight of lions and wolves.  It is estimated there are 20-30,000 lions left in Africa.  50 years ago there were 450,000 lions, a decline of more than 95%.  While historically their numbers had grown, the emergence of man as a predator of lions is the major factor behind their decline.

However, what is astonishing is that the majority of lions are still killed by other lions.  In some prides 80% of the cubs don’t survive.  Either they are killed by other males, or they don’t get enough to eat (they typically eat last in the hierarchy of the pride).  Lions evolved without a predator with an instinct to dominate the savanna from each other, not to share it.

The similar emergence of man as a predator of wolves resulted in the number of wolves declining by about a third.  However, their population is now relatively stable at about 300,000.  Wolves care for each other as individuals.  They form friendships and nurture their own sick and injured.  Pack structure enables communication, the education of the young, and the transfer of knowledge across generations.  The older wolves, as more experienced hunters, share hunting strategies and techniques with younger wolves, passing down knowledge from one generation to the next.

While lions collectively struggle because of their individual desire for dominance, wolves succeed because they cooperate and support each other.

The lessons for newly formed PCNs are clear.  Do we build PCN governance structures to ensure the most successful practices aren’t negatively affected by the practices that are not performing as well, or is the aim to support all practices regardless of their starting point, and to help those most in need to improve?  Do we share information, ideas, resources, expertise with other PCNs, or do we keep it to ourselves and leave other PCNS to work it out for themselves?  Do we collaborate with other PCNs to create a strong voice for general practice, or do we let inter-practice and inter-PCN disputes weaken our collective stance, as we argue against each other in public so that others can simply ignore the general practice position?

We should judge PCNs not on how they are performing relative to other PCNs, with metrics devised by the system, but on how well they are supporting their member practices, and the extent to which they are enabling general practice to thrive.  The more both practices within a PCN work collaboratively together, and PCNs work collaboratively together with each other, the more general practice will thrive.  It may even be we get to a place where “the strength of the PCN is the practice, and the strength of the practice is the PCN”!

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jun
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What is your Primary Care Network’s Purpose?

Posted by Blogs, The General Practice BlogNo Comments

I was sitting in a nascent PCN’s meeting recently, and watching the practices grapple with the challenges of forming a new network, and at the same time thinking of the quite common advice for PCNs to establish a common purpose.  Sitting there, I imagined saying to the practices that what they needed to do was spend time identifying and agreeing a common purpose, and equally visualised my rather speedy subsequent removal from the room.

I understand that forward thinking practices can get to the place of considering what the purpose is of their shared network.  But for most practices the current challenges are agreeing who will be in the network, who will be the leader, how they will make decisions, who will hold the money, and how they will deliver extended hours.  There is no time (or patience) for esoteric questions about purpose, when there is so much that needs to be done in the little time they have together.

Does that therefore mean that those PCNs who have not explicitly addressed the question do not have a purpose?  Or is the (unspoken) purpose enabling practices to do what they need to do to fulfil the contract, and receive the funding and resources to which they are entitled?  If there is no purpose at all, you could argue practices would have rejected the Network Contract DES.

Framed more positively, is, then, the (unspoken) purpose of PCNs to increase investment in, and the sustainability, of general practice?  Is it to reverse historic underinvestment and enable general practice to emerge from its current crisis?  Are PCNs in fact a “lifeboat” (as it was termed at a recent Nuffield Trust event) for general practice?

I co-authored a book entitled the Future of General Practice, in which we explored what practices who had emerged from the current crisis had done.  Broadly speaking they have introduced new roles, found ways of working at scale, and began to form partnerships with other providers in the wider system – all elements of the new PCNs.  Like them or loathe them, there is no doubt PCNs represent an opportunity for general practice to create a more sustainable future for itself.

Is it ok for the purpose of PCNs to be first and foremost about investment in and the sustainability of general practice?  As we discussed last week, the system wants PCNs to be about the integration of general practice with the wider system.  And can anything in the NHS be about anything other than improving outcomes for patients?

I would argue that if the system partners with a general practice that is essentially broken, the benefits will be limited.  And if supporting general practice is the way to improve outcomes for patients, then it is perfectly reasonable for that to be its primary goal.  Where general practice is in crisis, the purpose of PCNs needs to be to support them out of it.  Integration with the wider system, and improved outcomes for patients, will be happy bi-products of this primary purpose being fulfilled.

The challenge for PCN leaders is to be clear on the purpose of their PCN.  While the discussion might not explicitly have been had, GP leaders will know why their colleagues are turning up and what their expectations are.  I think there is actually real value in these leaders making the implicit explicit, and using this positive articulation of exactly what it is practices are doing together to give energy to the PCN from member practices.  Ultimately, practices, the wider system and patients will all benefit from this.

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jun
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What are PCNs: joint working between practices, or something more?

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There is an almost palpable dissonance that sits between the Primary Care Networks (PCNs) as constituted in the PCN DES, and how they are perceived in the minds of CCG leaders and those responsible for developing integrated care systems.

On the one hand the GP contract portrays the DES as a framework for practices to work together and to secure investment into general practice over the coming years.  The system, meanwhile, seems to think of PCNs as the building blocks of the local integrated care system, with a membership and remit expanding far beyond core general practice.

So who is right? Are PCNs a contractual construct of joint working between practices, operating solely within the framework of the national GP contract, or are they something more, owned more widely across the system and with an accountability beyond the terms of the GP contract?

This question is one general practice would do well to take time to consider, because the implications are far reaching.

A good place to start is the Long Term Plan for the NHS, published just before the new GP contract.  In chapter 1 of this document, which sets the direction for the NHS for the next 5 years, it sets out five major changes to the NHS service model, the very first of which is “we will boost ‘out-of-hospital’ care, and finally dissolve