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.

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.

This week our old friend John Tacchi returns with a guest blog on the newly published Primary Care Network agreement. A vital set of documents which will dictate the shape of PCNs for years to come.  John critiques the agreement…and doesn’t pull his punches.

NHS England has released the mandatory Network Agreement which all PCNs will have to sign. It consists of two documents, the agreement and the schedules. Given the importance of this document (bear in mind that in future, payments to GPs will increasingly be made to PCNs and less to individual practices), it is a bit thin. Terribly thin in fact. Rather than pick it apart, let us instead consider what it actually says and what is left in the hands of GPs to sort out for themselves.

The Agreement

This is the document that all members of the PCN must sign. It is categorically stated as ‘legally binding’ and so will govern the future relationship of the practices which make up the PCN and govern the flow of money. There are 106 clauses and you would be forgiven for thinking that this is where the ‘meat’ is. These cover general obligations and patient involvement, financial arrangements, workforce, information sharing and confidentiality, conflicts of interest, meeting format (governance generally), joining and leaving the PCN, duration and variation, termination, dispute resolution and ‘events outside our control’.

Except they don’t. The clauses in the agreement all refer to the schedules for greater detail. The schedules document is, however, a series of blanks, leaving PCN members to fill in as necessary. This is not particularly helpful and leaves GPs to sort out a host of vital issues themselves. The top 5 are:

Financial arrangements

There are so many issues under this heading. If one practice in the PCN is designated to receive PCN payments, how will it pay what is owing to other practices? When? On what basis (i.e. what happens if another practice does not provide the PCN services required)? How will be accounted for? What happens when there are other organisations other than practices involved? What about possible insolvency of a practice; how will this impact the PCN? What about intellectual property rights of individual practices/partnerships? How will these be protected? Can individual partners of member practices be sued for the liabilities of the PCN? No detail. Not good.

Workforce

Given the fact that money is being made available for additional roles (but not at 100% reimbursement), who will employ them? If the practice that is the designated fund-holder does, is it aware of the implications from an HR perspective? If another organisation employs them (i.e. a new company), there may be VAT issues. This has the potential to create horrendous problems.

Governance

How will the PCN decide on pressing issues? It will need to have some a ‘board’ of some kind and who will be on it? What will the role of Clinical Director be? Will representatives of the ‘board’ have authority to bind individual partnerships? What is the legal status of decisions made? What about liability issues? How will a PCN vary the agreement if it needs to? Many, many open questions.

Joining and leaving the PCN

This is probably the most glaring ‘omission’ (given the schedule simply says ‘fill in the blanks’). How do practices leave and are they even able to do so? Can a PCN expel a member practice? If so, how? If a PCN expels a practice, what becomes of the patient list? How will they still receive PCN services?

Dispute resolution

What happens if things go wrong? What is the legal status of member practices within the PCN? Who will act as arbiter in the event of a dispute?

Timing is obviously an issue. The network agreement and all its schedules must be signed by all member practices by June 30th.  This is not very far away! The current version does at least say that the agreement can be varied from time to time, but this first draft is so devoid of detail that PCN members really must get specialist advice before signing anything. Lawyers are expensive and it is only the national firms that have the breadth of experience to give a detailed view. They are very expensive. GP’s need specialist advice on this vital issue. And fast!

John Tacchi

Tanza Partners

www.tanza.co.uk

Last Friday (29^th March) the new Network Contract DES was published.  Six documents in all, and well over a 100 pages of weekend reading (my life is basically one big party).  Much of it restated what we already knew, but I will focus here on the important new things it contained.

There are a number of key changes to the submission requirements.  There has been some talk about the sizes of networks since the new GP contract was published, and how fixed the 30-50,000 population is.  More flexibility is now permitted for the upper end of the range, and where commissioners do agree to larger network sizes, “the PCN may be required to organise itself operationally into smaller neighbourhood teams that cover population sizes between 30 and 50,000”.  There can also be changes to network memberships after the 1^st July, but these will require 28 days’ notice, approval from the commissioner, and will only start the quarter after approval is received.

The network agreement now does not have to be submitted by the May 15^th deadline, but by the end of June.  Interestingly, it is in a mandatory form (one of the six documents published is the “Mandatory Network Agreement”), a theme reinforced by lines like “we agree that the wording in the clauses to this agreement may not be varied unless a national variation is published”.  There are, however, seven schedules at the end which do allow some variation, and, frankly, seem to me to mean that most networks will need the extended deadline to agree them.  For those interested in hypothetical future scenarios the agreement also includes quite a bit on (amongst other things) the process for leaving/joining networks, expulsion from, dissolution of, and dispute resolution.

More clarity is also provided on who can and cannot be the accountable clinical director.  It can be a clinician (i.e. not just a GP), but they have to be practising within the network area (no out of area leaders allowed).  Four options are suggested for the selection process: election, mutual agreement, selection, and rotation within a fixed term (the latter presumably the last option for those areas where no one is willing to step forward).

What is also new is networks have to be ready to provide extended hours from July 1^st, including having in place “appropriate data sharing arrangements”.  If this is done, and the network agreement is completed and signed, the PCN will be considered “established” (a term eerily reminiscent of “authorised” for those still bearing the CCG set-up scars).  Any delays in becoming established will affect payments, most notably the ability to claim the £1.50 PCN funding that will otherwise be backdated to April 1^st.

The new GP contract published at the end of January indicated the money for a network could be paid to a lead practice, a federation, an NHS trust or even a social enterprise.  All mention of that is gone in this guidance, which instead states that the recipient of the funding “must hold a primary medical contract” (i.e. a GMS, PMS or APMS contract), thus at a stroke discounting the majority of federations, NHS trusts or social enterprises.

How, then, federations might feature immediately becomes a less straightforward question.  The answer appears to lie in the recently published BMA Primary Care Network Handbook, which suggests one of the potential operating models for networks is to subcontract the provision of services and employment of staff to a federation.  Subcontracting in this way is allowed by this guidance, as long as it has the consent of the commissioner.  There is some complicated VAT guidance also provided, but my take is that as long as the twin traps of simply providing employment of staff (so falling foul of agency requirements) and of separating out clinical and non-clinical services into separate contracts, are both avoided then subcontracting by the networks to the federation is unlikely to incur VAT.

One of the other questions that has been doing the rounds is whether there is financial benefit in networks being smaller to secure proportionally more resources.  I think this guidance effectively puts that to bed by clarifying that even though each network (regardless of size) will initially receive 100% funding for a link worker and 70% funding for a clinical pharmacist, from April 2020 each network will receive a “single combined maximum sum… based on weighted capitation”.  So any advantage gained in 19/20 will be immediately lost the following year by having less left to spend on new roles the following year.  Indeed, the guidance states, “PCNs will not wish to make short term gains to the detriment of longer term sustainability”.

However, in 2019/20 practices can only use the workforce funding to appoint a link worker and a pharmacist, and cannot use the funding for any other roles.  The only flexibility is if a network either cannot recruit to one other of these posts, or already has a “full complement” of one or the other, at which point networks can substitute between the two roles.  The workforce funding for PCNs also means the clinical pharmacist scheme in general practice is being ended.  This means if practices have applied to the scheme, or even been approved for it but have not appointed a pharmacist, they will not now be eligible to go ahead.

The guidance also introduces the concept of “additionality”.  Essentially a baseline of staff numbers supporting practices across the five roles (clinical pharmacist, link worker, physician associate, extended scope physiotherapist, and paramedic) as of 31^st March this year will be taken through a combination of NWRS (national workforce reporting system) and a (mandatory for practices) survey by commissioners during April 2019.  The funding for additional staff will be given as long as networks can show that these staff are “additional” to this baseline number.

There is much in the guidance about the supervision and workload requirements of the new staff.  My worry is the level of restriction in the guidance, coupled with the cost pressure and associated liabilities each new member of staff funded at 70% (or less) of total cost presents, may lead to a much lower uptake in the recruitment of the new staff than those writing the guidance are seemingly predicting.

Overall, as is the tendency of all detailed guidance, whilst it may provide some much needed clarity, enthusiasm for the changes will inevitably be dented by the sheer weight of the new instructions.  While some aspects are helpful, some are clearly not e.g. the change to the hosting arrangement options, and the lack of flexibility around workforce funding.

At the heart of the new GP contract was a desire to create a sustainable future for general practice, and yet what seems to be most lacking in this guidance is any focus on how all of this will benefit core general practice.  The challenge for local leaders will be first to understand this guidance, but then, more importantly, to translate it in a way that can still inspire local GPs and practices to make the most of this new opportunity.

More information was recently published by the BMA on primary care networks.  You can read it here.  I would regard it as essential reading for all GPs and practices who are considering joining a network.   But at 30 pages it takes some working through, so for the time poor I have summarised below what it says about the questions not answered in the initial contract document.  The answers provided are essentially quotes from this new BMA handbook.

Can CCGs influence the shape of the new Primary Care Networks?

The only involvement of the CCG in this process should be when there are gaps in the total PCN coverage of their area. (the document’s highlighting, not mine)

The content of the network agreement is not within the remit of the CCG to challenge. As long as the practices have agreed, the CCG cannot refuse the DES based on its content.

What agreement is required between practices in a network by 15^th May?

To be recognised as a PCN, individual GP practices will need to make a brief joint submission outlining the initial network agreement signed by all member practices.  This will specify how the member practices will handle network-specific issues such as:

• decision making, governance and collaboration arrangements
• arrangements regarding the delivery of different packages of care
• the agreement for distribution of funding between the practices
• arrangements regarding the employment of the expanded workforce
• internal governance arrangements (appointment processes, decision making process, etc).

Who can be clinical director of a primary care network? Does it have to be a GP?

It is expected that the clinical director will be selected from the GPs of the practices within the network, but any appropriate clinically qualified individual may be appointed.

While there is no requirement for the clinical director to be appointed from within the network, we recommend that the first option should be to consider an appointment from within.

How will Primary Care Networks make decisions?

Each network is to have a governing/representative body.  This network “board” should operate as the network’s governing body, bringing all members together, overseeing joint decision making, the strategic direction of the network and the network’s funding/financial layout. It is also the body to which the clinical director would be directly accountable.

The network will need to decide:

• what is within the remit of the clinical director to act executively, what needs to go back to the practice representatives
• how the governing body makes decisions – does it require a simple majority, a conditional majority, unanimity, etc
• how often the governing body should meet
• how meetings are chaired (an elected chair, rotational chair, etc). As the clinical director will be accountable to the governing body, it may be better for the role to be excluded from chairing the governing body

What will the operating model of Primary Care Networks be?

Key issues to consider when establishing an operating model include employment liabilities, ability to offer NHS pension, and inadvertently attracting VAT charges.

5 potential operating models for networks:

1. “Flat practice network” – practices work together and spread responsibilities and commitments, with one practice acting effectively as the network bank account.
2. “Lead Provider” – a lead practice takes responsibility for engaging the workforce and entering into contracts
3. “GP Federation/Provider Entity” – the provider entity is subcontracted to deliver services required by the DES and to employ the staff
4. “Super-practice as a network” – a super-practice creates an internal ‘network’ amongst its constituent sites, with each ‘neighbourhood’ of practices operating as a mini network in themselves.  The super-practice would be the nominated payee and would then supply support and resources to its constituent neighbourhoods.
5. “Non-GP provider employer models” – the non-GP provider is signed up to the network agreement, along with the GP practices. They provide network services and employ staff available under the DES on behalf of the network, as well as using their own staff to further enhance the network’s potential workforce.

All primary care networks will need management and administrative support structures.  Practices that form the network will also need to seek advice on any proposed legal agreements and financial matters, and will need to establish a regular meeting of their representatives to ensure that things are developing as planned.

What will Primary Care Networks actually do?

Networks will develop expanded practice-based and connected teams to deliver the provision of workload support of the member practices by:

• working alongside the existing practice team and taking responsibility for some services of the member practices (to be decided by the network), focusing on extended-hours delivery in the first instance
• restructuring some service delivery (to be decided by the network)
• offering access to the extended PCN team (extending the workforce).

The funding currently associated with the Extended Hours DES will transfer (with the associated responsibilities) to the network. This will be provided as an entitlement to the network’s nominated bank account of £1.45 per patient. The network will decide how this funding is distributed in line with the provision of services required to fulfil the requirements of Extended Hours.

The £6 per patient that is currently provided for the Extended Access scheme will also transfer to the networks; the exact timing of this transfer will depend on the current arrangements in each area for the Extended Access scheme… The intention is to bring together extended hours and extended access activity to reduce fragmentation and confusion for practices and patients.

How will the funding for the new PCN workforce role work?  Will smaller networks receive (proportionally) more funding?

There will be funding for the clinical lead post for each network on a basis of 0.25 WTE per 50,000 patients, at national average GP salary (including on-costs) (of £137,516).

For the first year of the DES (2019/20), every network with a population of at least 30,000 can claim 70% funding as above for one additional WTE (whole time equivalent) clinical pharmacist and 100% funding for one additional WTE social prescribing link worker.

The level of funding available for a PCN will scale with its size. This will be especially true in future years when workforce funding switches from direct reimbursement to a capitated payment, based on the population size of the PCN.

Over the coming years…the workforce reimbursement system will be altered so that it is linked to the patient population of the PCN.

The network will need to provide a monthly invoice with evidence of costs to its CCG, and will be reimbursed the required amount up to the maximum reimbursement. The maximum reimbursable amount for each of these roles will be set at the weighted mid-point of the respective Agenda for Change salary band.

There are no mandated contractual terms for staff employed under the PCN DES.

Can the funding be used for additional staff practices have already employed?

Staff employed under the DES must be ‘additional’ to the existing workforce employed by the network’s member practices. This will be measured on a 2018/19 baseline established as of 31 March 2019…The only accepted exception will be those clinical pharmacists employed via either the national Clinical Pharmacist in General Practice scheme and Pharmacists in Care Homes scheme.

How are practices expected to fund the 30% staff costs (for roles where only 70% funding is provided)?

2 options:

• Use the network payment (e. the £1.50 per head).
• Practice-pooled funding (e. contribution from each practice)

Who will be responsible for distributing the network funding?

How funding could flow in a network – 4 examples:

1. “Flat practice model” – expenses shared across member practices
2. “Lead practice model” – a single practice takes sole responsibility
3. “GP federation/provider entity” – the limited liability provider entity takes responsibility
4. “Non-GP employer” – the non-GP healthcare provider takes responsibility

Can my CCG decide not to provide the required funding for networks?

Commissioners cannot remove or reduce the entitlements, but they can add to them.

Commissioners may choose to transfer, where appropriate, their locally commissioned services contracts to the network, rather than with individual providers.

Are Primary Care Networks just a precursor to general practice becoming part of Integrated Care Providers?

A more controversial model of integration, the ICP (Integrated Care Provider) has also been introduced by NHS England. ICPs involve merging multiple services into a single contract, held by a single provider. ICPs have been subject to controversy and the BMA has been clear that we oppose their introduction, as they increase the risk of privatisation and are incompatible with the independent contractor status of GPs.

It is easy to get lost right now in the immediate challenge of identifying practices to be in a network with, persuading someone to be the ‘accountable clinical director’, and deciding who should hold the network bank account.  But to get these short term decisions right it is worth spending some time reflecting on exactly what primary care networks are supposed to do.

This starts with their place in the wider system.  The new GP contract says, “The Primary Care Network is the natural unit for integrating most NHS care. Collective general practice can become the footprint on which other NHS community-based services can then dock. And by serving a defined place, the Primary Care Network brings a clear geographical locus for improving health and wellbeing.” (p25)

How networks will start to enact this bold claim is also spelled out in the new contract.  There are seven services networks are to provide against national specifications.  After the set-up year of 2019/20, there are two initial services to be delivered in full in 2020/21.  Networks are to provide structured medication reviews to patients, focusing on particular priority groups.  The pharmacists employed during 2019/20 will be key to the delivery of this service.

They are also to provide a new enhanced service for care homes.  This might be the first new service requiring networks to agree differential delivery across practices, e.g. a lead practice for one or even all of the care homes.  A condition of signing up the network agreement is that services will be provided equally across the network population, and it is becoming immediately apparent networks won’t work via a simple equal division of labour across member practices.

Worth a further pause at this point.  Many CCGs up and down the country have commissioned these types of schemes locally.  It would seem the use of the national GP contract, and its new network function, will lead to the replacement of many locally commissioned schemes with nationally commissioned ones.  We should watch out for how much opportunity the imminent Network Contract DES indicates there will be for local flexibility.

There are three further services that are to “commence in 2020/21 and develop over the subsequent years”.  This is where general practice is taken into slightly less well chartered territory.  While the first service, anticipatory care, is fairly common across the country (although under different names such as “proactive care”) and the idea of identifying and proactively managing the needs of high risk patients is nothing new, what is new is that this service will require a “fully integrated primary and community health team”.   Community providers will even be asked from July to configure their community teams on primary care network footprints.  The relationship (and power dynamic) between the primary care network and the newly configured community team will be critical to future success.

Which takes us back to the wider purpose.  The network is very much about enabling the integration of primary care with other parts of the NHS system.  “A Primary Care Network cannot exist without its constituent practices, but its membership and purpose goes much wider. The NHS Long Term Plan sets out a clear ambition to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. The Primary Care Network is a foundation of all Integrated Care Systems; and every Integrated Care System will have a critical role in ensuring that PCNs work in an integrated way with other community staff such as community nurses, community geriatricians, dementia workers, and podiatrists/chiropodists.” (New GP contract, p30-31).

The next service is “personalised care”.  Easy to say, hard to understand exactly what it is.  I have read the relevant parts of the new contract a number of times and I still find it hard to pin down.  It seems this is essentially about widening the support provided to individuals beyond purely medical interventions.  Social prescribing and the newly funded link workers will play a prominent role in the delivery of this service.  However it plays out, it is another step in widening the scope and role of general practice through networks in influencing the overall health of local populations.

The last service to be introduced in 2020/21 is supporting early cancer diagnosis.  What is most interesting about this service will be the role of networks in raising awareness of symptoms and uptake of screening in their local neighbourhoods.  Networks may provide a way of practices operating more freely outside of their practices with local community partners.

Finally, in 2021/22 two more services will be introduced.  Cardiovascular disease prevention and diagnosis and, more nebulously, tackling inequalities.  Whilst the former is relatively clear, the latter much less so.  The text in the contract is along the lines of “we will test some ideas and then roll out the approaches that have the greatest impact at the network level”.

Alongside these seven new services from 2020 there will be a new national “Impact and Investment fund”.  Based on a principle of “shared savings” it means networks can gain a financial return from reductions in A&E attendances, emergency admissions, outpatient costs, prescribing savings, and hospital discharge (I assume via reduced length of stay), to then invest in new staff for the network.

It seems, then, the real work begins for networks in 2020 with the introduction of these specifications.  The immediate challenge then should not be simply to tick the relevant boxes that will be sent out by the centre, but rather to use 2019/20 to develop a platform that will be able to deliver against these future requirements, or even better one that can make a real difference to the health and wellbeing of the population it will be serving.

The clock is already ticking. Following the recent publication of the new GP contract, GP practices only have until the 15th May to submit their network registration information to their CCG. Waiting until the Network Contract DES is published (promised by 29th March) will only leave 6 weeks. Starting now gives practices three months to get ready for the new networks.
But where to start? It is tempting to jump straight in to what the network will look like and how it will operate. But a better place to start is with “why?” Why will this network exist? What is its purpose? What difference is it going to make?

Simon Sinek talks about this lot. His book, “Start with Why”, has inspired many. For the time poor, you might want to cut straight to this 5 minute short version Ted talk to understand the essence of it. Essentially, people are inspired by a sense of purpose. It is this that motivates us to take action. Clarity on why we do things leads to much more sustained action than clarity on what we are to do or how we are to do it.

The GP contract offers a number of possible motivations for primary care networks. They are (p25):

• “Intended to dissolve the historic divide between primary and community services”
• “A way of helping GP partnerships survive and evolve over the coming decade, and provide a means of mutual support for better workload management”
• “A dedicated joint investment and delivery vehicle”, a way of enabling investment into primary care where it cannot reasonably be expected for every practice to deliver the requirements on their own”
• “Large enough to run a full multi-disciplinary team”, a way of bringing new roles into general practice”
• “A clear geographical locus for improving health and wellbeing”
• “To provide strategic and clinical leadership to help support change across primary and community health services”

Each area is different. One, some or all of these may work for you. More likely there will need to be some adaptation, some local tailoring, to create an ambition that is inspiring for your GPs and the practice staff in your network.

It will be easy to get lost in creating a network simply because you have to. Or in tactics to try and maximise income received. Or in the details of how the network will operate. But networks present a huge opportunity for general practice, not just for now but for many years to come. Decisions made in the next 3 months are like to have long lasting consequences because these networks will grow in importance.

Even though time is short, time invested now in determining the why of their network for member practices will be time well spent. It will create unity, excitement even, and a shared sense of purpose. It will make delivery down the line much easier, and sustain action well beyond the initial network submission deadlines.

On the surface the new GP contract and the GP Forward View (GPFV) appear very similar.  Both contain promises of money and staffing, as well as a determination to create a sustainable future for general practice.  But nearly three years on from the publication of the GPFV, things don’t feel much better.  Workforce, finance, workload and morale all remain challenges for general practice.  Will it be any different this time round?  We’ve been examining the differences between the two documents, and have identified 5 that give cause for optimism.

1. Type of document

While both are written documents, there is a big difference between the GPFV and the new GP contract.  The GPFV was essentially a commissioning plan – it was how NHS England, as the commissioner of general practice, was going to improve it.  It was full of aspiration, but lacking in detail of how it was going to be delivered, a concern that ultimately proved well-founded.  The new GP contract, however, is just that – a contract – and as such is clearer and more transparent, making the promises feel much more concrete than in the GPFV.

2. Money

On the surface the promise of money is similar.  In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years.  The problem the GPFV ran into was transparency in relation to the money.  The RCGP and others set up tracking mechanisms to try and check the promises made were being adhered to.  In the end, because the £2.4bn was actually to be delivered over 8 years (a retrospective starting point of 2013 was used), and because a huge chunk of it went on access and so not to core general practice, it never made the difference it should have.  The new contract is different.  Yes £1.8bn of the £2.8bn comes via the new networks, but it is still coming to practices, and how the money will be delivered is clearly laid out.

3. Implementation

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.  This time the money will come via the contract, either directly to the practice or directly to the network set up by the practice.  It feels like control of the funding will sit at practice level and then work up, rather than (as with the GPFV) start at the top and slowly trickle down.

4. Policy Objective

Politicians and commissioners always want a return for their money.  In the GPFV the primary policy objective was extended access (‘we will invest this money in general practice if you deliver 8-8 working 7 days a week’).  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 private providers.  In the new contract the primary policy objective is the introduction of primary care networks.  These networks are to enable general practice to integrate more effectively with the rest of the system, and allow a more robust system of out-of-hospital care to be created.  The great news for general practice is that, done well, these networks can support and enhance the delivery of core general practice.  This alignment of the needs of general practice with overall policy provides maybe the greatest hope for the new contract.

5. Workforce

One of the biggest failings of the GPFV has been its inability to successfully tackle the workforce crisis in general practice.  The service is still waiting for 5,000 of the promised 5,000 additional GPs.  The new contract, however, takes a more realistic approach.  The focus on new GPs isn’t lost, but is enhanced by a much more pragmatic (although still challenging) plan to recruit 20,000 additional non-GP non-nurse clinical staff, with the funding being directly provided to the practices via networks.  This realistic plan for staffing creates a strong foundation for optimism.

Reading the NHS Long Term Plan (LTP), the GP Partnership Review, and the Planning Guidance for 2019/20 (not something I would recommend for a single sitting!), one thing stands out for general practice above everything else – Primary Care Networks.  When it comes to general practice, the documents make it clear that Primary Care Networks, based on neighbouring GP practices that work together typically covering 30-50,000 people, are the new black.

They are seen as the enabler of “fully integrated community based healthcare” (LTP p15).  They will have expanded neighbourhood teams, which “will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and AHPS such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.” (LTP p14).

And not just an enabler of integration.  The GP Partnership Review wants more.  It says, “Multi-professional community health teams should be based in Primary Care Networks and work under the clinical and service direction of the Primary Care Network.  They could remain employed by their existing employer while being more closely partnered with, and embedded in, practices day to day.  This should include creating a single team using a common health record, sharing the same caseload, and removing the need for referrals.  Wherever possible, the community teams should also be co-located with the constituent practices of the network.” (Partnership Review 4.46 p30).

The future role of Primary Care Networks does not stop there.  They are the vehicle for online consultations: digital-first primary care is to become a new option for every patient, and to enable this the NHS, “will create a new framework for digital suppliers to offer their platforms to Primary Care Networks on standard NHS terms” (LTP p26).  The GP Partnership Review recommends an even stronger role in relation to access, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends…NHS England should consider how existing funding for extended access and opening could be allocated through Primary Care Networks as they mature, to enable local decision making on managing demand appropriately” (Partnership Review p32).

They will provide around the clock cover for care homes, “Primary Care Networks will also work with emergency services to provide emergency support (to care homes) including where advice or support is needed out of hours” (LTP p16)

They should be training hubs.  Dr Nigel Watson in his review recommends, “every Primary Care Network should be in partnership with, or become, a Training Hub, ensuring the place-based delivery of education and training in primary care for GPs and other staff working in general practice and staff aligned with the Primary Care Network” (Partnership Review 4.51 p31).

They are to be the new voice of general practice.  “Every Integrated Care System will have… full engagement with primary care, including through a named accountable Clinical Director of each Primary Care Network” (LTP p30).

They will be responsible for health outcomes.  “Primary Care Networks will from 2020/21 assess their local population by risk of unwarranted health outcomes and, working with local community services, make support available to people where it is most needed” (LTP p17).  They will also be encouraged to reduce expenditure.  “We will also offer Primary Care Networks a new “shared savings” scheme so that they can benefit from actions to reduce avoidable A&E attendances, admissions and delayed discharge, streamlining patient pathways to reduce avoidable outpatient visits and over-medication through pharmacist review” (LTP p15).

How is the move to Primary Care Networks going to happen?  Well I suspect we will find out more when the new GP contract is finalised.  For now, the LTP says, “As part of a set of multi-year contract changes individual practices in a local area will enter into a network contract, as an extension to their current contract, and have a designated single fund through which all network resources will flow.  Most CCGs have local contracts for enhanced services and these will normally be added to the network contract” (LTP p14).

In 2019/20 CCGs are required, “to commit a recurrent £1.50/head recurrently to developing and monitoring Primary Care Networks so that the target of 100% coverage is achieved as soon as it is possible and by 30 June 2019 at the latest.  This investment should be planned for recurrently and needs to be provided in cash rather than in kind” (19/20 Planning Guidance p17).

It remains to be seen if that sets a “running cost” of £45-75K per network (assuming 30-50,000 population), or whether it is a starter fund with more to be added later.  One place we might find out is in the primary care strategy that every ICS or STP must have in place by 1 April 2019.  This strategy is to set out, “how they will ensure the sustainability and transformation of primary care and general practice as part of their overarching strategy to improve population health… This must include specific details of their: local investment in transformation with the local priorities identified for support; Primary Care Network development plan; and local workforce plan” (19/20 Planning Guidance p17).

The ambition for fledgling Primary Care Networks, that in some places do not even exist yet, is breath-taking.  They are clearly a crucial building block in the design of the new system for the NHS.  Whether they can live up to the expectations remains to be seen, but they represent a huge opportunity for general practice.  Like them or love them, because even funding is being channelled through them, they are a trend that will be almost impossible for general practice to ignore.

You’ve seen the summaries of the NHS Long Term Plan but now, thanks to a guest blog from Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) we offer you a more in-depth look from the particular perspective of general practice operating at-scale…

I’m a long-term cynic when it comes to NHS long-term plans.  They’re usually unnaturally narrow, overly prescriptive and with the flexibility of a Soviet Five Year Plan.  This new one is different: it’s broad (scattergun broad in places), with vision statements instead of hard plans, and enough scope for local areas to interpret this in a way that makes it work for their area.

Be open when you read it, if you don’t like one part then don’t write off the entire plan.

The sections below are my commentary on each chapter in the plan, concentrating on Chapter 1 and putting a very strong at-scale bias on it.

CHAPTER 1 – SERVICE MODEL

The changes to the existing NHS service model in this plan are generally well thought through and represent some good innovative thinking.  There is substantial work needed, though, to turn it from vision into actual plans.  For at-scale General Practice, the Plan has plenty of changes:

The focus around Primary Care Networks (PCNs) is interesting as it’s a deliberate step away from discussing “providers” and into defining geographically bound GP-led organisations.  There is almost no other way they could have phrased this without allowing a way-in for out-of-area and private company poaching of work.  How this is funded is a different question, as it’s vague.  I would prefer a capitated block budget with a deprivation supplement (see Chapter 2 notes).  It will be interesting to see how this will work with looking-out GP Federations mixed with looking-in PCNs.

Additionally, it refers to CCG procured “enhanced” services.  This is a particular issue of mine as cash-rich CCGs can afford lots of these enhanced services while cash-poor ones can’t.  It’s a built-in inequality that directly impacts the way clinicians can offer patient care. It would be good to see a national index of enhanced services offered in each area.  Maybe this is something for NHSE to do, enabling GPs and providers to hold CCGs to account for the reduced capabilities they have.

A very welcome change in this Plan is the addition of “shared savings” where GPs and PCNs will be rewarded by getting part of any savings made in other care settings.

There is now a focus on “digital first” for GPs.  I think this partially misses the point as it does not account for the system-wide savings through continuity of care in General Practice. Neither does it work for the “have-nots” of society who can’t or won’t use technology. This is where GPs must step up and be the patient advocates for the have-nots, especially in deprived areas.

I would recommend a priority for GPs is to address this themselves to protect their own service.  For example, it’s allowable in this for patients to be offered telephone appointments OR online conference ones.  Show that you offer patients a teleconference option and change your model to prioritising it and you’ll be half-way to meeting this objective. Do it yourselves or you’ll find it mandated and patients going elsewhere under promises of remote unicorns of same-day GP appointments by phone.

The outpatient redesign part of this chapter concerns me as, unless it’s done properly, it’ll result in General Practice being dumped with patients overly quickly discharged or there being clear rationing or higher bars on referring patients.  The Plan risks getting this wrong.  Patients don’t just go away because they can’t get a referral to hospital.

A major focus is placed on moving all of England to the ICS model by 2021. This is too aggressive as some areas just will not be ready in time.  Areas with large system-wide deficits or strict system controls are most likely to have difficulties in setting up effective ICS because it’s just not a priority compared to that big financial black hole

Another aspect of ICS is the move to Integrated Care Provider contracts. This will require legislative change to enable, but will effectively shortcut alliances of NHS public providers into formal status while also allowing a complete removal of the necessity for procurement for work in the area. A concern is the Plan suggests only allowing this for statutory bodies.  While this will exclude the big private providers, such as Virgin, it will also exclude GP Federations.  Much is required to make this work, and the elephant in the room of Brexit makes legislative changes unlikely for quite a while.

CHAPTER 2 – PREVENTION AND HEALTH INEQUALITIES

This chapter concerns itself with the prevention agenda and addressing health inequalities.  It does it very well and makes a strong case for addressing deprivation related health inequalities.  For this alone, this Plan succeeds and deserves support.

The Plan is clear that more funds will be targeted at areas with high deprivation and high health inequalities.  The concern for many areas with high deprivation is that they’re often grouped with areas of middling or low deprivation and any aggregation of their “scores” would see a loss of any such deprivation premium.

I would like to see a central strategy of highlighting discrete areas of high deprivation and high health inequalities and mandating special funding for them.  A secondary, but just as important, strategy is that this extra money must not be allowed to be diluted across an ICS/system; it must be provided to help health inequalities among the most deprived patients in England, not to give extra to areas that don’t need as much help.

CHAPTER 3 – CARE QUALITY AND OUTCOMES

This chapter is a mixed bag of strong content matching chapter 2 and defensiveness over the consequences of previous decisions.

The cancer prevention and early diagnosis parts of this Plan fall heavily on primary care with extra resources being made available for urgent referrals and diagnostic tests.  It will put pressure on GPs to deal with the turnaround and meet targets but it is achievable and will help patients.  A critical component is the funding though and ensuring it comes before the targets.

There’s a strong focus on mental health with distinctions between CYP and adult MH, as well as plans for addressing the current service gap of 18-25-year-old patients moved from CAMHS to adult MH services. Much of the load from this will land on primary care through IAPT extensions, and it’s worth dedicating time to what this will mean for both individual practices and at-scale General Practice. I’d recommend that GP Federations make this a core part of any clinical strategy they’re developing.

One thing that will benefit patients is the commitment to get 70% of acute hospitals to the Core 24 standard on emergency MH support by 2023/4 and then to 100%. This will give GPs a much needed emergency referral source that is missing at present across the greatest part of England.

The less good side is learning development and autism where the plan seems disjointed and is proud of the fact that inpatient provision will be halved by 2023/4 considering that it was already effectively cut in half from its 2010 numbers by 2015.  As always, the load from these patients moved back to the community risks landing on primary care and often take GP time.  Again, we need a GP at-scale strategy for these patients to treat them with the dignity and care they deserve while also not impacting overall workloads.  The relatively low numbers would suggest this may be best dealt with in practices with at-scale support.

Interestingly, there are some changes to the planned vs urgent care model that will help primary care. There are plans to provide funding for increased planned care capacity, but not necessarily in acute hospitals.  This is a welcome change from the now habitual “cut referrals” strategy to reduce waiting lists.  Also, there are plans to force physical separation between urgent/emergency care and planned care so that disruptions such as winter pressures will have fewer major impacts on planned care.  This would be a major expense though, and I doubt the government will provide the capital needed for the physical building separations.

CHAPTER 4 – NHS STAFF

Of greatest importance to GPs in this section is the confirmation that GP indemnity will be cost neutral.  This means it will be paid for but then clawed back through other parts of GP funding, most likely GMS/PMS contracts.

The remainder of chapter 4 shows this is the weakness of the whole Plan. It needs a robust workforce strategy and struggles without it.  Treat this chapter as a placeholder for the proper strategy later.

There is too much concentration on the centralised functions writing the plans and far too little recognition that it’s locally that workforce fails when grand strategies are applied.

It also shies away from changing previous poor decisions, such as materially defunding the NHS Leadership Academy, but talks about improving training & CPD coverage.

CHAPTER 5 – DIGITALLY-ENABLED CARE

There’s some blank cheques written in this section that recognise the aims of the Health Secretary, but these haven’t yet been fleshed out beyond bare skeletons.

A key example is the paragraph about improving IT to make work more satisfying (“faster, better and more reliable”).  Yet with no ideas on how they’ll do that when programme after programme has failed to touch the subject.

It also fails to deal with the massive infrastructure upgrade of resilience that is essential if the NHS is moving away from on-site presence to off-site coverage.  If a system goes down or is slow when the patient and clinician are face-to-face then it’s often simple to work around; if a system goes down when it’s a virtual consultation then it usually stops. This is a massive expense, based on my own experience of grand-scale upgrades, doubling the capital IT budget for a few years MIGHT just achieve this.  There’s no getting away from this, to make it “faster, better and more reliable” will require huge and probably politically unbearable capital investment with revenue uplifts.

CHAPTER 6 – TAXPAYERS’ INVESTMENT

The Plan bakes in a 1.1% annual “productivity growth” dividend.  This is unlikely as there’s very little “fat” left in the system.  The NHS as it stands is far more efficient than the vast majority of even the best private sector organisations.  Any more cuts will be right into muscle.

It does make an interesting comment that community care clinical staff spend more time doing admin and non-patient facing work than patient-facing work. I would put that this is a recognition that admin cuts have gone too far and investment in specialist admin staff and tools would more than repay themselves in freed time to deal with patients.

Finally, it makes the point that the central admin budgets of the NHS, including provider Trusts, will be expected to be cut by £700m/year.  Again, from where?

CHAPTER 7 – NEXT STEPS

An interesting point here is the Plan’s aim to provide five-year indicative budgets.  My hope is that this will remove the year-by-year short-termism of the NHS and allow long-term efficient and multi-year budgets. This is an area where Federations and private providers can outperform the NHS at present as we’re not bound by in-year spending of funds.  It will only be good for the rest of the NHS to catch up.

The legislative changes required to make this plan work are also interesting.  The bits that impact at-scale General Practice are around the ICS/ICP and integrated care Trusts and the removal of procurement mandates.  The latter would allow CCGs to make direct contracting between NHS organisations easier and remove the significant wasted costs we see in NHS procurements of very low-level services.  Both are items that should gain strong support and advocacy from GP at-scale groups.

WHAT IT’S MISSING

I hope some readers are still here!  As a bonus to those of you who made it, I noted two major areas that this Plan misses that I’d hope would make it.

Point 1: National detailed minimum standards of care matched to local needs.  Targets are fine in their own way (same with CQC inspections) but they’re negative and, regardless of what they say, just are not patient focussed. I would like a grand programme that sets standards of care across all health issues and provokes discussion on prioritisation for care to help the NHS set its own localised plans.  For example, what’s unique about a deprived area’s health inequalities that explains WHY it has lower levels for patient care?  What does that mean and how does the area plan to meet, and exceed, national minimum standards of care?  Long-term local plans should then be externally funded for removing health inequalities matched with central funding for delivery that supplements local commissioning funding.

Point 2: Demand analysis.  The NHS is woefully unaware of its actual demand.  How many patients don’t bother when they can’t get a GP appointment?  How many GPs won’t refer clearly ill patients because they know they’d be rejected?  The NHS is terrified of these figures as they’d be spun out of all proportion by the media, but they’re needed to model demand properly.  The NHS needs an adult conversation on demand and how it should be met, including what we expect the public to do themselves.  It’s a weakness to continue scaling services by supply rather than demand.

As mentioned, this is my interpretation with my tinted glasses on of at-scale General Practice. I instinctively wanted to dislike this Plan before I read it but I actually do like it.  It’s honest and doesn’t pretend to be complete, it also is a vision statement where you can forgive the lack of detail as long as there’s a genuine aim to produce proper plans in a relatively short time.  With that in mind, give it your own read with that in mind rather than “that won’t work”. https://www.longtermplan.nhs.uk/

In February Jeremy Hunt announced there would be a review of the partnership model of general practice, and that it would consider “how the partnership model needs to evolve in the modern NHS”. This review makes me nervous.

The number of GP partners is falling. As all practices are only too well aware, the number of applicants for a GP partner post has fallen dramatically, with many adverts not attracting a single serious application. General practice has to be attractive to the GPs of the future. The review will need to look into this, and discover nuggets such as “the prospect of unlimited personal liability in a hugely under-funded sector has limited appeal to new GPs”.

I am nervous about this review because it is very easy to conflate the issues facing general practice as a whole (the workload, workforce and financial pressures) with the partnership model. It is easy to imply it is the partnership model causing the challenges rather than the historic underfunding etc. etc. Correlation, regular readers of this blog will recall, is not the same as causation. If general practice was still receiving 11% of NHS expenditure would we still be having this review?

A review of the partnership model is also a review of independent contractor status. General practice is currently very difficult to control. The independent contractor status affords it an ability to act only according to what is negotiated within its contract. Changes to NHS rules don’t directly affect it. Persuasion rather than coercion is required, and for politicians seeking rapid change in general practice I can imagine this is hugely frustrating.

There is a widely-espoused view that the small business, or “corner shop” model of general practice is no longer fit for purpose. As the NHS seeks to move into a world of integrated care a new, bigger version of general practice is required that can partner with the rest of the system. Most sectors of the NHS can be instructed to actively participate in integrated care arrangements (or individuals moved on), but not so general practice. The sheer number of practices is making progress painfully slow, and there is no direct command lever that can be pulled to make integration happen any faster.

However, size and form are two different things. GP partnerships, operating as independent contractors, can operate at any scale. They are not limited in size. Our Health Partnership has done an admirable job of demonstrating how the partnership model can work at a population scale of over 300,000. Conflating the relatively small size of general practice organisations with the partnership model of general practice when they are two distinct issues is, at best, unhelpful.

The review makes me nervous because although the partnership model does not need to change for general practice to operate at greater scale, it does need to change if the system is to exercise greater control over general practice.

The only thing making me less nervous about the review is the appointment of Dr Nigel Watson, Chair of Wessex LMC to lead it. He appears to be a supporter of the partnership model. He recently said,

“My personal view is that the partnership model has not reached the end of the road, it can still have an important role to play in the future of the NHS but we need to make it a better place to work, which will encourage more GPs to remain working in general practice, address the concerns about the unlimited personal liability and with the move to a more population based approach to healthcare ensure that general practice is truly able to play a leadership role in the local NHS.”

The review does indeed need to consider these things, and build on the strengths and freedoms of the partnership model as it looks to the future. Let’s hope my nervousness (and, I admit, my cynicism) is unfounded.

It is now two years since the publication of the GP Forward View (GPFV). Do things feel any better? Not for most GPs. In a recent Pulse survey 80% reported their workload had worsened over the last two years. So why has the promised £2.4bn recurrent investment, with all the trimmings alongside, failed to have any impact so far?

Looking back, I wonder what the GPFV was. Was it a strategy document? Not really, because there was no clear sense of direction. A recovery document for a service in crisis? Maybe, although it was written at arm’s length from GPs as providers. I think it was a commissioning plan, or commissioning intentions at a stretch. It was what NHS England, and the CCGs, would do to support a service in crisis. It was also a public, political document designed to demonstrate the concerns of GPs had been heard and were being addressed.

Understanding what the document was gives an insight into why it is not working. The headline investment figure of £2.4bn was an overstated figure. The real five-year investment plan was under £1bn. But the figures were extrapolated back to 2013 (the details are here) to inflate the figure to £2.4bn. Promising more than is going to be delivered is a sure-fire recipe for underwhelming results.

A cynical view of the document is that it was also a very clever way of packaging the extended access agenda to make it palatable to GPs, at a time when many were close to breaking point. While the share of funding for general practice within overall NHS expenditure has not really changed, the challenges of GP recruitment have not been addressed, and workload continues to rise, the one clear “success” of the document is that extended GP access is being introduced across the country. Ask any CCG which of the targets in the GPFV they are most closely monitored on and they will tell you it has been all about access. While the problems in general practice have not been alleviated, the government’s primary agenda for the service is being delivered.

There are some good things in the GPFV. The Releasing Time for Care programme and the work of Robert Varnum on the 10 high impact actions, which I admit I was initially sceptical about, I now think is possibly the most impactful part of the document. Practices changing themselves is the only realistic way out of the crisis, and this programme empowers and enables practices to do this. The support for indemnity looks like it is heading in the right direction, and the funding for new roles such as pharmacists has definitely helped.

But the reality is the workforce crisis persists (1,300 full time equivalent GPs left between September 2015 and September 2017), the workload continues to grow, the capital investment through the elusive ETTF simply has not materialised, and funding remains insufficient. Worse, the rhetoric around the GPFV has put general practice to the back of the queue when further funding is announced, e.g. the chancellor’s pledge of an additional £2.8bn to the NHS at the last budget had nothing earmarked for general practice.

Our collective failure to understand what the GPFV as a document was means we are now left without a clear plan or sense of direction for general practice. We initially thought (wrongly) the GPFV provided this, but what it needed (and what it still needs) is a provider led response to say this is how we will use the commissioner promises made in the GPFV to deliver a new future for general practice, and this is what it will look like. There are enough green shoots out there (the primary care home, the great work of NHS Collaborate, and the 108 episodes of the GP podcast are all testament to that) for this to be possible. But without it, either at a local or a national level, I fear the situation will be worse in 2021 than it was when the GPFV was published.

Are patients consumers? It is a question that has vexed those trying to introduce a market into healthcare for many years, and I think it is fair to say the consensus view is captured in Dr Jordan Shlain’s article, “There are no consumers in healthcare, get over it”.

He summarises that this is a consumer:

1. They have freedom to make choices based on their resources and their numerous options
2. They can decide not to make a choice
3. They add something to their lives (material or experience) after a purchase
4. They have a trust psychology based on being excited, not anxious
5. Consumers get immediate or near immediate benefit from their purchase

And this is a patient:

1. They often do not have freedom to make a choice and the options are limited
2. They must make a choice
3. They are trying to get rid of something (pain, nausea) and have no idea of the cost
4. They have a psychology based on anxiety
5. Patients often have no line of sight into whether they get a benefit or not

According to Wikipedia, a patient is “any recipient of health care services”. But how does prevention fit in to this? If a GP surgery undertakes preventative activity with its local population, is it doing that with them as patients or as consumers? When I as an individual decide to go for a run to improve my health, am I a patient or a consumer?

Let’s apply Dr Shlain’s criteria for consumers to my choice to go for a run:

1. I can choose whether or not I go for a run
2. I can decide to stay at home watching TV on the sofa instead
3. I feel more healthy (as well as slightly smug and self-satisfied) after I have been on a run
4. I am excited to lose weight, improve my fitness, and to (feel like I) look better
5. I feel great as soon as I have completed my run. My phone tells me how far I have run, at what speed, and how long it took. I can share it on social media and gain feedback from my own network.

So while there may not be consumers in healthcare, there are certainly consumers of health. Why does this distinction matter? It matters for two reason. First, if general practice is serious about changing the pattern of demand, of shifting the focus from healthcare for the sick to wellness for all (as described by Dr Amit Bhargava in our recent podcast), then the nature of the interactions need to be consumer-focussed rather than patient-focussed. We will need something very different from our current system of patient participation groups, something more along the lines of the “Beat the Street” initiative described by Dr William Bird.

Second, the big technology companies (e.g. Amazon, Apple etc) already understand that individuals are consumers of health. Their moves into healthcare are predicated on being able to reduce total expenditure by empowering individuals to manage their own health.

“Apple, Google, and Amazon are trying to lower the cost of health care for their employees by steering them toward outpatient clinics and wellness programs that they own or control…There is a potential convergence going on now. Electronic medical records, mobile phones, and wearables have achieved widespread adoption, creating new opportunities.”

Technology can make a real difference to us as consumers of health. But the opportunities for Apple, Amazon and Google are also opportunities for general practice. The risk is if general practice does not take them, it might be superseded by the technology companies who do.

Dr Shlain may be right that there are no consumers of healthcare, but there are consumers of health. The aging population and the rapid advancement of technology mean this distinction is more important than ever before, and its impact upon primary care is likely to be huge.

At an appearance before the Commons Public Accounts Committee in February this year, Simon Stevens signalled the end of the purchaser provider split, indicating that the development of accountable care organisations by STPs would dissolve historical boundaries between commissioners and providers.

These boundaries were first established by the NHS and Community Care Act in 1990. Even then two types of “purchasers” were created: Health Authorities, and general practice through fundholding. Fundholding was abolished by Tony Blair and the new labour government in 1997. Instead, Primary Care Groups and then Primary Care Trusts emerged, with GPs given a voluntary role through practice based commissioning. This voluntary role became compulsory in 2013 with the establishment of CCGs.

The commissioner/provider split has always been an artificial one, particularly for general practice. It was introduced to create a healthcare market, based on the theory it would create value for money by purchasers shopping around for care provision. But the requirement to sustain existing providers, the creation of perverse incentives to increase activity, and transaction costs not being matched by innovation has led many, including it seems Mr Stevens, to the conclusion it just does not work.

The entire commissioning “experiment” has not served general practice well. Divisive at first (e.g. fundholding vs non-fundholding practices blamed for creating a two tier system for patients), a “primary care led NHS” became one of the mantras of the late 1990s and 2000s, using the public trust of GPs to soften the blow of a nominally left-wing government maintaining the internal NHS market. With the advent of CCGs, all practices were mandated to become part of the commissioning system. All practices were to become both providers and commissioners of care. Conflict of interest regulations were developed to manage this dual role, which became increasingly cumbersome over time. In turn, practices had to split their leadership resources, energy, focus and talent between these commissioner and provider roles.

This happened at a point where the profession (as providers) was plunging into crisis. Ironically, the boundaries between the commissioning and provision roles of GPs left them powerless to use their position as commissioners to ensure the required shift of resources into the provision of general practice actually took place.

And now the purchaser provider split is to end. What does this mean for general practice? Most obviously it means the role of local GP commissioners will be side-lined, to be replaced by providers working together in accountable care systems. However, this shift will evolve locally, meaning GPs will continue to expend effort, time and energy into commissioning, while providers develop a new future.   The artificial split between commissioning and provision enforced upon practices in 2013 is to be abandoned, but not yet.

General practice as providers, however, are to be included in the development of accountable care organisations. But not as individual practices. Instead they need some at-scale representation. Here general practice is at a real disadvantage. Some of its limited pool of leaders, talent and energy remain tied up in CCGs. At-scale organisations in some areas do not even exist, and in many areas are new, and not really able to partner as equals with established local hospitals and the like.

There are, however, opportunities. The capitated based budget systems for accountable care organisations may incentivise systems to strengthen general practice, and remove the incentives for growth in secondary care activity that the internal market has generated. The removal of the artificial commissioner/provider split for general practice is an opportunity for the profession to become “whole” again with a much clearer identity. And for all their ills, CCGs have enabled a cadre of GP leaders to gain system leadership skills over the last 4 or 5 years, that can be deployed by the profession within the new care delivery systems.

Making the most of these opportunities requires action. The world is changing quickly, and in many places general practice has been slow to respond. The cohesion of practices attempted (but often never really achieved) by CCG locality structures and the like needs to be delivered by practices themselves. A strong, single voice is required. Practices need to ensure they are around the STP and accountable care “table” as providers, represented by their best leaders. In some places it will need early decisions by GP leaders to move out of the commissioning arena to focus on provision.

The purchaser/provider split has not served general practice well, but it is coming to an end. It is time to draw a line under it, to focus time and energy solely on the provider role, and to build a strong future for general practice in the post-commissioning world. Lack of action now, however, could lead to a new (albeit different) set of problems that may pose a more fundamental challenge to general practice in the future.

Hidden away in the latest NHS England publication[1], on page 19, is this graph (above). It is not good news for general practice.

At first glance it would seem to present a positive picture. Spending on general practice has gone up, and is planned to continue to go up until 2021. So what is the problem?

In the General Practice Forward View, published in April 2016, an additional recurrent investment of £2.4bn was promised to general practice. The parlous state of general practice was at last recognised, and (or so it seemed) that recognition was backed with real cash.

But what this graph shows is the additional investment of £2.4bn did not begin on the date of the publication of the paper. It begins around 2013, some three years earlier. A specific highlight is given to the formation of NHS England, to correlate this date with the turnaround in the funding fortunes of general practice.

The implication of this graph is that those awaiting £2.4bn of investment should really only expect less than £1bn between now and 2020/21. The graph also indicates the rate of funding increase will slow compared to the last two years. Worse, £500m of the extra money still to come has been promised for extended access, and at present most of that funding is being awarded via private tender, and not to local practices.

This should not be about headlines or political statements. It should be about properly funding a critical part of our NHS. It is no wonder that GP partners are at breaking point. According to one recent survey more than 90% of GPs have either left, have considered leaving, or have reduced their hours to be able to cope[2]. The additional funding is not a reward for general practice. It is what is necessary to keep it functioning and operating effectively at the front line of the NHS. This graph shows that not only is the funding required not going to materialise, but that the system is also going to pretend that it is.

[1] Next Steps on the NHS Five Year Forward View, March 2017

[2] http://www.weloveourgps.co.uk/

Every year CCGs receive planning guidance from NHS England, which tells them what needs to be included in their local plans for the coming year. In his latest Blog Ben Gowland explains in detail what this latest round of guidance means and why this year is different – and not all good news.

This year there have been a few changes to the Planning Guidance. The guidance has been produced earlier, in September, and plans and contracts are to be complete and signed by December, and cover 2 years instead of one. Each CCG has to produce a local GP Forward View plan by 23^rd December (regardless, it seems, of whether they have chosen to take on delegated responsibility for the direct commissioning of general practice or not).

So what can general practice learn from the newly published guidance? The detail it contains (along with the subsequent local plan) was only ever going to be one part of a 3-piece jigsaw – the other two parts being the national GP contract award and the local STP plan. Combined these three will give us a really good picture of what the real impact of the GPFV is going to be in the coming years. But a few things stand out.

For a start, the headline £2.4bn uplift, so prevalent and heavily featured in the GPFV, does not get a mention. In some ways I understand this as the £2.4bn was set for 2020/21 and the guidance is only until 2018/19, but nonetheless it is a concern.

This concern is exacerbated when the starting point for investment is the NHS England 5 year allocations for primary care. The final per capita growth in 2017/18 is 2.41% (compared to 3.16% in 2016/17), an amount that varies considerably across the country (from 0.45% in NHS South Norfolk CCG to 10% in NHS Islington CCG). In 2018/19 it is lower still, at 1.75%. Across the 5 years these allocations create a £1.1bn recurrent investment in General Practice, which on its own will not be enough to increase the general practice share of total NHS expenditure nor keep up with inflation of expenses in general practice.

That isn’t of course the end of the story. What was exciting about the GPFV was the other recurrent £1.3bn that would make up the £2.4bn, as well as a promised £508M non-recurrent package of investment in the meantime. The new guidance contains more details of both of these.

£500m of the additional recurrent £1.3bn was always going to come for access.   What the guidance says about this is that in 2017/18 and in 2018/19 the GP access fund sites (formerly the Prime Minister’s Challenge Fund sites) will receive £6 per weighted head of population. The CCGs without GP access fund sites will receive £3.34 per head in 2018/19, and £6 per head from 2019/20. This isn’t great news for 2017/18, because according to the GPC £6 per weighted head of population is less than the GP access fund sites currently receive, and if you are not a GP access fund site you won’t be receiving any additional access money until the year after.

For this money, CCGs have to commission services 8am-8pm during the week, and at weekends, “provide access to pre-bookable and same day appointments… to meet local population needs”. At least 8-8 on Saturdays and Sundays has been avoided. In capacity terms they must provide an additional 30 minutes extra consultation capacity per 1000 population, rising to an extra 45 minutes.

Where the remaining £800m of the £1.3bn is going to come from is still something of a mystery. The guidance says further investment will come from:

• Increases in funding for GP trainees funded by Health Education England

• Increases in funding for nationally procured GP IT systems

• Increases in the section 7A funding for public health services, which support payments to GPs for screening and immunisation services

• 3,000 new fully funded practice-based mental health therapists to help transform the way mental health services are delivered

But none of that feels like real money coming into practices. It will be interesting to see whether money will come to practices to directly employ mental health therapists, but if that was the plan I think more would have been made of it by now. But maybe this gap provides an opportunity for investment into the core contract, or into general practice via the STP plans. We will need the other two pieces of the jigsaw to find that out.

This still leaves the promised non-recurrent investment of £508m. The headline here is that CCGs have to find £171m of it from their core allocations (i.e. they haven’t been given any extra money for it), and this equates to £3 per head. This money is to, “stimulate development of at scale providers for improved access, stimulate implementation of the 10 high impact actions to free up GP time, and secure sustainability of general practice”. CCGs can choose whether to give this to practices in 2017/18 or 2018/19, or spread it across the two years. The guidance also says CCG funding to general practice should increase beyond the level of their core allocations (2.14% in 2017/18 and 2.15% in 2018/19), but I can’t imagine for one minute cash-strapped CCGs will be able to fund this on top of the £3 per head.

This non-recurrent fund also contains a number of other smaller pots:

• Online general practice consultation software systems – £15m available in 2017/18 and £20m in 2018/19, specification yet to be shared.
• Training care navigators and medical assistants for all practices – £10m available in each of 17/18 and 18/19, specification yet to be shared
• General Practice Resilience programme – £8m available in each of 17/18 and 18/19 (compared to £16m this year)
• Time for Care national development programme – nationally funded, CCGs to identify a senior local leader

At the same time NHS England will be investing (non-recurrently) in international recruitment of GPs, clinical pharmacists in general practice (3 years funding for practices), and expansion of physician associates, medical assistants and physiotherapists. The bids put forward for capital investment are also being considered.

And that is it. The significant investments are essentially those for access and the £3 a head by CCGs. What we are left with is a sense that the two year planning timeframe could work against practices in areas that don’t have a GP access fund site, and so won’t be receiving any additional access money next year, and whose CCG chooses to invest its £3 per head in 2018/19. For them, unless there is significant assistance coming via the STP plan or the national contract negotiation, 2017/18 could well be an even more difficult year than the one we are currently in.

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