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3
mar
0

Does Integration Really Mean Centralisation?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.”

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. Privileged to work with such a talented and motivated team!

— Jacob Haddad (@jacobnhaddad) March 9, 2020

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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!

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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”?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by IanBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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”

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

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

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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!

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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

Posted by IanBlogs, The General Practice BlogNo Comments

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

  • Future NHS Collaboration Platform https://future.nhs.uk/connect.ti/socialprescribing/groupHome hosted by the NHS Personalised Care Group – Request membership via england.socialprescribing@nhs.net and then access the Social Prescribing pages/Regional pages/Regional Discussion Forums
  • Social Prescribing Network – https://www.westminster.ac.uk/patient-outcomes-in-health-research-group/projects/social-prescribing-network and @SocialPrescrib2 on Twitter
  • Twitter Social Prescribing Wednesday – @SocialPresHour – every other Wednesday and hosted/organised by Elemental
  • Friday afternoon (4:30pm to 5:30pm Fridays, 10am-11am Monday) Social Prescribing email meet-up social-prescribing@googlegroups.com Apply for membership at https://groups.google.com/forum/#!forum/social-prescribing or email sam@agileventures.org if having difficulty.
  • 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…

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

26
jun
0

Pack or pride – how should PCNs operate?

Posted by Ben GowlandBlogs, 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”!

19
jun
0

What is your Primary Care Network’s Purpose?

Posted by Ben GowlandBlogs, 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.

12
jun
0

What are PCNs: joint working between practices, or something more?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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 the historic divide between primary and community services” (Long Term Plan p12).

How will this be achieved?  Through PCNs. Through the investment of £4.5bn in “expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices… Most CCGs have local contracts for enhanced services and these will normally be added to the network contract… The result will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care” (Long Term Plan 1.9-1.10 pp 14-15).

There are some important points to note here.  First is that, in case anyone is in any doubt, the primary purpose of PCNs is the integration of primary care with the rest of the system.  The contract has been used as a necessary mechanism for setting them up.  How else can you integrate independent contractors?

Second, is that the promised £4.5bn in the Long Term Plan is considerably higher than the £1.8bn promised in the GP contract to support the formation of PCNs.  This is because the majority of investment in PCNs will not be through the core GP contract.  The funding that comes from other sources (which, by the way, represents a huge opportunity for general practice) will, inevitably, bring with it an accountability outside of the core contract, and into the wider system.

The other place to look is the PCN Network Contract DES, which notes the key features of the DES are set out in the Long Term Plan (and so references the points above without explicitly stating them).  It says the DES is subject to annual review and development, and that the focus in 2019/20 is “to support the establishment of PCNs and the recruitment of the new workforce, with the bulk of the service requirements coming in from April 2020 onwards” (Network Contact DES Specification p5).

So this year (the easy one) is about practices working together, and essentially getting ready for what is to come from 2020 onwards.  That is when the shift will accelerate away from core general practice.  The Network Contract DES guidance states, “PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care. To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.” (p16-17).

One of the service specifications coming in 2020/21 is the innocuous-sounding anticipatory care, “The Anticipatory Care Service will need to be delivered by a fully integrated primary and community health team. To support this, from July 2019 community providers are being asked to configure their teams on PCN footprints. The requirements will be developed across the country by ICSs, and commissioned by CCGs from their PCNs. NHS England will develop the national requirements for the essential contribution required under the Network Contract DES.” (p18).  Within one of seven DES service specifications the NHS has effectively announced the full integration of primary and community care!

Back to the original question – are PCNs about contractual joint working between practices, or about integrating all services within a local community?  While today the answer is largely the former, it is clear from 2020 onwards the answer is very much the latter.  There is no real dissonance (other than between the expectations of pace setting system leaders and the reality of where their local networks are).  PCNs are on a journey.  The start of this journey (and where we are today) is joint working between practices, but very quickly this will evolve into joint working between that group of practices and the rest of the local health and social care economy.  This is the DES practices have signed up to, and these are the changes that are on their way.

5
jun
0

Guest Blog – Clare Allcock – Accelerating Collaboration in Primary Care

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

To support her excellent podcast this week, our special guest Clare Allcock from Kaleidoscope Health and Care has provided us with a very useful infographic outlining the ways in which new networks can accelerate the pace of successful collaboration.

29
may
1

Primary Care Networks: A Roadmap until the end of June

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

While many have sat back and breathed a collective sigh of relief that the 15th May deadline was met for the submission of the initial PCN returns, that was unfortunately only the start of the journey.  Some pretty formidable challenges lie ahead.

I am sure some PCNs have a clear plan and are meticulously ticking off actions and making sure everything is sorted as they get ready for the 1st July, when PCNs formally begin.  This is less for those PCNs, and more for the time poor and those who have that feeling there is something they should be doing but they are not sure exactly what! It also doesn’t cover everything you could be doing (if that’s what you need do watch out for Clare Allcock’s wonderful advice on how to accelerate collaborative working in next week’s podcast).  Rather this is designed to help you meet the minimum requirements.

Essentially, each PCN has to complete three key actions by 30th June:

  • Agree how extended hours will be provided at a rate of 30 additional minutes per 1,000 registered patients to all registered patients within the PCN.
  • Ensure appropriate data sharing agreements and, if required, data processing arrangements are in place, using the national template, to support the delivery of extended hours.
  • Ensure the network agreement is completed (including all seven schedules), and signed.

For the provision of extended hours, each PCN will need to know:

  • Does each member practice wish to undertake the delivery of extended hours for their practice population?
  • If any practice does not, is there another practice willing to take the delivery of these hours on?
  • If not, is there a third party who can deliver the services on behalf of the practices?

It is easiest if each practice does their own extended hours, next easiest if there is some sort of buddy arrangement between practices so that they can cover each other, and least easiest if you have to create some new model of joint working across practices.  That is not to say one model is better than the others, only which is easier in terms of the amount of work each will require in the month until the next submission is due.

Now you may be lucky and already have data sharing agreements in place between your practices.  If you don’t, then there is the promise from NHS England of a national template.  Unfortunately, the PCN frequently asked questions states that this is not yet available as it has to be agreed with the GPC.  Watch out for its publication, as you are not going to have long to turn it round and get it agreed by your member practices.

As for completing the network agreement, remember the starting point for each PCN is the mandatory network agreement (here).  This mandatory agreement cannot be altered.  However, there are 7 schedules where additional clauses can be added.  The template for completing the schedules can be accessed here.

I am not a lawyer, so this is not legal advice, but if you had to prioritise you could go with the suggested wording of the national agreement and not worry too much about schedule 2 (essentially this schedule is where you can make changes/additions to some of the mandatory network agreement), and for schedule 6 you could go with the suggested list of insolvency events (it is essentially a list of different events of insolvency that would enable members to take action under the clauses).  The difficult bits you would then have to sort out are:

  • The rest of schedule 1 (you have already done some of it) where you have to say how the meetings will take place, what is quorate, how you will make decisions etc etc
  • Schedule 3 where you outline everyone’s responsibilities in delivering extended hours
  • Schedule 4 where you have to outline all the network’s financial arrangements (how much money each practice is getting and who is going to pay it)
  • Schedule 5 where you set out the arrangements in the PCN for engaging or employing staff, including arrangements for employment liabilities
  • And schedule 7, which is essentially how you will work with any other organisation (e.g. a federation). Top tip here is get them to draft it for you, and then change their version, rather than starting with a blank piece of paper.

I don’t know how many meetings you are realistically going to have with your practices between now and the end of June, but if it isn’t many you may want to find someone to draft a starter for 10 for each of these schedules.  If you can agree 90% of them remotely, then you can use any valuable meeting time to focus on the hopefully small number of areas that are left.

And once you have done all that, you are probably going to need to get a lawyer to look over the final agreement with all its appendices before you can persuade your practices to sign it.   Remember the submission of the network agreement is due by 30th June which (inevitably) is a Sunday, which means the 28th June, which means there is only one month to go to get everything done.  No pressure!

What would be really helpful would be sharing across PCNs of good ideas for improving the agreement between practices, strong additions to the network agreement, and good wording for the schedules.  Anything we find along the way we will definitely pass on.

I hope that is useful.  If you have any advice for over-stretched incoming PCN leaders that I have missed please do get in touch to share.  Good luck all!

22
may
0

Guest Blog – Tara Humphrey – Introducing New Roles

Posted by IanBlogs, The General Practice BlogNo Comments

This week we are delighted to feature a useful guide from our old friend Tara Humphrey, founder of THC Primary Care. Tara appears on this week’s podcast talking about the introduction of new roles to Primary Care Networks. You can find that here.  In support of that podcast Tara has provided us with a written guide to the practical stuff you’ll need to know and you can download that by clicking on the link below:

Tara New Roles

15
may
1

PCN Deadline Day: 8 Lessons we have learnt so far

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

Primary Care Network submission day has arrived!  3½ months have passed since Primary Care Networks were formally announced as part of the new GP contract for 2019.  What have we learnt in the intervening period?  I would suggest there are (at least) 8 key lessons.

  1. PCNs represent the biggest change for general practice in a generation. While PCNs may have started life as only one part of the package that was the 2019/20 GP contract, it has become clear they represent a much more fundamental change for general practice.  Funding flows into the profession are set to shift from being primarily at an individual practice level, to being primarily at a PCN level.  The fates of GP practices within a PCN are set to become inextricably intertwined.
  2. 15th May was an ambitious deadline for PCN submissions. The initial expectation was practices would have their network agreements in place by today, but as the complexity of that particular task became clear the deadline for the full agreement was relaxed to the end of June.  Practices choosing whom to get into bed with has taken most of the last few months (and some may still not be there yet!), and the challenge of defining the nature of the agreement between them still lies ahead.
  3. The lawyers are coming. What wasn’t clear at the outset was how defined the nature of the network agreements between the practices needed to be.  NHS England has produced a “legally binding” mandatory network agreement for all practices to sign up to, but the meat of this agreement has been left to schedules that need to be developed and agreed locally, which will inevitably require lawyers.  It will be hard to keep the focus on trust and building relationships, which is widely agreed to be the most important foundation for a successful network, once the lawyers are in.
  4. Focus has shifted away from the sustainability of core general practice. In the context of the new GP contract, PCNs were heralded as the mechanism for enabling new funding and resources to flow into general practice.  But on top of the legal fees, each new role requires practices to dip into their pockets to finance the unfunded elements, and the funding for extended hours has been cut.  The talk surrounding PCNs has quickly moved towards “system integration” and equally quickly away from the sustainability of PCN member practices.
  5. The gap in funding for new roles is high risk. As practices have picked through the funding of the new roles, they have found that the headline 70% is an optimistic assessment of the national contribution.  This contribution is fixed regardless of the local market for the roles, or the package the network ultimately has to offer.  Financial liability for the new roles, for example in the case of redundancy, also sits with the practices in the network.  Whether all networks take up the offer of the new roles remains to be seen, but it appears increasingly likely at least some will not.
  6. PCNs represent a shift in system GP leadership. CCGs always had the problem that they represented their population not their practices, despite being membership organisations.  The introduction of PCNs coincides with a 20% cut to the management costs of CCGs and a likely move to a wave of mergers, making CCGs yet more distant from local areas.  At the same time PCNs will each hold seats on the integrated care system boards, as the means of providing “full engagement with primary care” (Long term Plan 1.52).  There is a clear shift of power in motion from CCG GP leaders to PCN Clinical Directors.
  7. The role of Federations is uncertain. Federations were conspicuous by their absence from the Long Term Plan and the new GP contract, and it is clear that PCNs are flavour of the month.  It remains to be seen the extent to which PCNs will work together effectively through federations, or whether each PCN will plough its own furrow.
  8. Expectations of PCNs at practice and system level are very different. There are grand plans for PCNs in the Long Term Plan, as the focus of developing place-based care and integrating services around local communities.  But the challenges facing front line GP practices have not gone away, as the recent Panorama programme highlighted.  Practices need PCNs to first support and enable their sustainability, whereas the system expects them to first prioritise delivery of their own plans.  How that tension plays out remains to be seen.

We are still at the very outset of PCNs.  Establishing them may have been the easy step, compared to some of the questions that remain unanswered and the challenges that lie ahead.

8
may
0

Will the PCN Voice really count?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The Long Term Plan published in January of this year said, “Every integrated care system will have… full engagement with primary care, including through a named accountable Clinical Director of each primary care network.” (1.52)

The GP Partnership Review, published shortly afterwards, said, “Working at scale, for example through Primary Care Networks, has the potential to improve and support general practice influence at a system level.” (p35)

The question is will the establishment of PCNs and the new Clinical Directors really mean that general practice has a voice, and be able to influence outcomes (and the flow of resources) at a system level?  You could argue the establishment of Clinical Commissioning Groups as statutory bodies was supposed to achieve just that, yet they have presided over one of the worst periods of under investment into general practice in NHS history.  Clearly setting up an infrastructure doesn’t of itself necessarily translate into a bigger voice.

Of course, some might argue, CCGs were commissioning organisations and PCNs are provider organisations, so this time it is different.  It is hard for the average GP not to be cynical about yet another promise that “this time it is different”, after so many previous identical promises failed to deliver.

We are heading in the direction of c1000 Primary Care Networks (PCNs) across England.  There are 44 STPs, so we are looking at c20 PCN Clinical Directors per STP.  Even though this is hugely more manageable for system leaders than 7,000 GP practices (c150 per STP), it is difficult to overestimate the challenge for each one of those 20 Clinical Directors trying to influence for their particular PCN.

In the model of “place-based care” (NHS-talk for providers from across health and social care working together at a PCN level), you could argue PCN Clinical Directors will be leading and shaping the integration of services locally.  However, this also depends on whether the reality of how place-based care works is bottom-up (decisions made by local teams), or top down (decisions made at STP level, and PCN leaders asked to implement them).  This in turn will depend on how influential the PCN leaders are at STP level.

The challenge facing the new Clinical Directors of PCNs is formidable.  They have to introduce joint working across GP practices that have never really worked together previously, and manage all the inevitable internal disputes and conflicts that will arise, before they can even start thinking about how they will work with local partners, and how they will create a strong voice for local general practice.

My sense, however, is that it is important to start as you mean to go on.  While the odds may initially be stacked against PCN Clinical Directors, the reality is the system needs them more than they need the system.  There is the opportunity to influence, but only if it is seized and taken from the start.  It is not going to come on a plate, and the new leaders of primary care will need to work hard to establish their voice.  Done badly, the voice will not be strong.  But done well, I think there are many gains to be had for PCNs, their practices, and their local populations.

It is with this in mind that here at Ockham Healthcare we have created a brand new (free) guide for PCN CDs on how to establish an effective voice.  It includes 10 practical steps PCN leaders can take to make their voice effective.  If you are already on Ockham Healthcare subscriber you will receive the guide free via our weekly newsletter on the 9th May.  If you are not a subscriber just sign up here (for free) and we will email you a copy.  I hope you find it useful, and good luck with finding your voice.

1
may
0

Guest Blog – The new Primary Care Network Agreement

Posted by IanBlogs, The General Practice BlogNo Comments

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

17
apr
1

Federations vs Primary Care Networks

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

There is a tension developing in some quarters between the existing GP federation and the emerging Primary Care Networks (PCNs).  It is like they are trying to compete for the same ground (at-scale general practice), and the result is a growing discord between the two.

A conversation develops about what the federation “offer” is for the new PCNs: will it be for all of the £1.50 per patient running cost, or just a proportion of it?  And what do the PCNs actually get in return for this investment of their money?  Federations can feel they have to justify their offerings, and PCNs can feel they might not be getting value for their investment.

What about the existing work of the federation?  Much of it, such as the delivery of extended access, is funded through monies that in future will be coming through the PCNs.  Will this work continue in its current form, or will the new PCNs demand a different model of delivery to that insisted on by the commissioners?  If it changes, will the GP federation even have a future?

It is easy to understand why tension between the two develops.

For me, however, this tension misses both the point and the opportunity of general practice operating at scale.  Inherent to both PCNs and GP federations is a membership of GP practices (generally the same GP practices).  The point of working together (whether because they choose to or “have to” because of the new GP contract) is to be able to better serve these member practices and their populations.  This is true for both PCNs and GP federations.   The practices are the underlying constant.

So the best place to start the conversation between federations and PCNs is not who should be doing what, and how much they are going to be paid for it, but one between the member practices as to what the relationship between the two is going to be.  The conversation should really be between the practices themselves, working out what they want to do together at PCN level, and what at federation level, and then to organise themselves accordingly.

For me, the most logical step is for the new clinical directors of PCNs to either become the Board, or at least have a majority on the Board, of the GP federation.  This removes the unhelpful sense of competition between the PCNs and federation, and instead enables the PCNs (as the group closest to practices and that hold the majority of the funding) to ensure the federation delivers exactly what the PCNs need.

There is no reason why existing GP federation directors can’t stand and become clinical directors of the new PCNs.  I was asked recently as to whether this would be a conflict of interest.  This question only makes sense if your starting viewpoint is one of competition rather than collaboration between federations and networks.  If the role of the federation is to serve the networks, not only is it not a conflict of interest but it is a pragmatic response to the emergence of PCNs.

For areas that have a GP federation the opportunity exists to have the best of both worlds – scale where it is needed, and a focus on individual local needs.  A GP federation and PCNs working in harmony can secure more investment and resources, create efficiencies by reducing duplication, establish robust and tailored mechanisms for service delivery, limit liabilities, improve patient outcomes, and strengthen the collective voice of general practice.  But whether practices can take this opportunity may depend on their ability to ensure the conversation is focussed on how to deliver the most benefit to practices, rather than one that is competitive between the two.

10
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0

Primary Care Networks: Learning from the Past

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“What has been will be again, what has been done will be done again.  There is nothing new under the sun” Ecclesiastes 1:9.

Primary Care Networks (PCNs) may be the shiny new toy of today, but of course they are not completely new.  At their heart they are about practices working together, about the introduction of new roles, about securing a vibrant future for general practice, about joining general practice more closely together with the rest of the NHS, and about making a difference to local populations.  These are challenges GP practices have been grappling with for a number of years now.

In 2016 at Ockham Healthcare we started the General Practice podcast, and have featured case study after case study of GPs, practices and groups of practices who have been innovating and finding new ways of working to tackle these challenges.

We also published, “The Future of General Practice. Real Life Case Studies of Innovation and New Ways of Working”, in which we highlighted 16 of these case studies, analysed why they had been successful, and distilled the lessons that could be learnt from them. What strikes me now is that this learning is more relevant than ever, to accelerate the progress and impact PCNs are able to make, and to avoid the mistakes of the past being repeated.

The case studies include a focus on introducing new roles.  We considered the impact of pharmacists, first contact physiotherapists, and paramedics, and how they could reduce the workload of GPs.  Even more interestingly, we looked at the development of multidisciplinary teams in general practice, and in particular how in some places they have transformed the management of on the day demand and the whole experience of being a duty doctor in a practice.  Key lessons included starting with the person not the profession, keeping a focus on building a wider team not on individual roles in isolation, and the need to stage appointments of staff over time.

Just like new roles, working with other practices is not new.  There are many experiences out there of what to do and what not to do that those involved in setting up the new PCNs would be wise to pay heed to.  We looked at case studies of mergers over a time period, multiple mergers at the same time, as well as the establishment of a super-partnership.  A whole range of benefits of at-scale working were realised, such as improved resilience, a better ability to manage demand, and greater profitability.  However, we also found simply working at scale does not automatically generate these benefits, and highlighted some important lessons for practices working together to make these a reality.

A key focus of PCNs will be partnering with other organisations, but again this is not completely new ground for general practice.  In the book we considered case studies of practices working with a hospital, with a community trust, with community pharmacy, with the voluntary sector and the local community.  We looked at the benefits general practice was able to achieve through this, such as access to staff, back office support, financial gains, and also what factors seemed to make these particular relationships successful compared to areas where relationships are poor.

There are now less than 75 copies of “The Future of General Practice” left.  To help those who want to learn the lessons from the past as they create the future with PCNs, we are making them available for only £9.99, a discount of over 60%, for as long as stocks last.  Click here for your copy.  The fastest way to success is always to learn first from those who have gone before you.

3
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What is new in the network DES specification and guidance?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Last Friday (29th 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 1st 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 15th 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 1st, 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 1st.

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 31st 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.

27
mar
0

How can Federations help Primary Care Networks?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Amongst all the furore that primary care networks are creating it is easy to lose sight of GP federations. The role of federations in the new world of primary care networks is unclear and not prescribed. So do they really have a future? If they do, what will it be? This week, I explore how federations could help the nascent primary care networks meet four of the biggest challenges they face.

Challenge 1: Managing the new clinical staff and the associated liability

By 2024 a typical (50,000 population) primary care network will have 5 clinical pharmacists, 3 social prescribers, 3 first contact physiotherapists, 2 physician associates and 1 community paramedic. That is a lot of staff. Who is going to manage the employment risk (and associated liability) for these staff? Some will arrive with considerable amounts of NHS service, making the potential employment liability very high.

Federations established as limited liability vehicles can not only take this risk away from GP partners, but can also add real value to the recruitment, management and development of these staff. When multiple networks are seeking to recruit from this limited pool of new staff, why will they select one area over another? If a federation can offer peer support, professional development, and (probably most importantly) structured support for both practices and staff in the implementation of these new roles, they will make their area more attractive to these staff, as well as ensuring the networks gain the greatest possible benefit from them. It is hard to overemphasise the importance of change management support to go alongside the recruitment of these new roles.

Challenge 2: Maximising the available financial resources and minimising the financial risk to practices

The new GP contract suggests that a typical network will have funding for additional role reimbursement of £726,000 by 2023/24. At 70% this creates a potential cost pressure for networks of up to £311,000. As a side note it has been suggested (e.g. in the BMA primary care handbook) that the £1.50 management allowance could be used to offset this, but the total management allowance for a 50,000 network is £75,000 – well short of the total amount potentially required.

It is on the finance side and meeting the “30% challenge” that federations can really come into their own. Federations can:

• Limit liabilities through an incorporated structure
• Attract further investment. Many CCGs and local integrated systems will want to invest in general practice, but will want to do it at a scale that maps to boroughs or historic commissioning areas, and federations providing an infrastructure across multiple networks will be an attractive vehicle for them to do so.
• Make the £1.50 management allowance go further. A typical network can’t hope to include delivery support, administrative support, communications and engagement, HR, financial support and leadership support with £75,000. But multiple networks working together could easily do this.
• Create other economies of scale. The £6 per head for extended access is a great example of a resource that if used collectively across a wider area through a federation could generate a significant return to constituent networks.
• Establish strong financial governance. A small but effective finance team within a federation can ensure financial risks are minimised, financial efficiencies are delivered (e.g. in relation to what funding is superannuable), and income opportunities are maximised.

Challenge 3: Ensuring delivery both across practices and with other organisations

Networks are not simply constructs that need to be created. There is a delivery expectation upon them, both across constituent practices and with local organisations. Five new network specifications kick in in April 2020, probably alongside the requirement to sort out extended access, plus any local enhanced serviced the CCG may want to add in to the mix. How will one network operating on its own get its head around all of the new delivery requirements? The nature of the new specifications mean it will not be as simple as passing them on to the member practices and simply asking each to do its share. New delivery models will need to be developed, agreed with practices and local organisations, and implemented.

It may be on the delivery requirements of networks that federations can add the most value. Resources can be dedicated to each of the network specifications, for example a clinical lead and a lead manager for each, who can negotiate with local practices, organisations and commissioners to create locally-tailored delivery models. Sharing resource and expertise in this way through a federation can reduce duplication and enhance local delivery.

Challenge 4: Meeting the leadership challenge of networks and creating a powerful local voice

Much is expected of the new “accountable” network Clinical Directors. They are to become the voice of the network in the plethora of integrated care meetings locally, as well as leading the development and delivery of new services, and sorting out any inter-practice issues – all in roughly one day a week. Nationally we have heard of a desire for new leaders to emerge from practices to take on these roles. These could be very challenging and isolating roles for potentially inexperienced leaders.

Networks operating together within a federation can do a number of things. They can provide leadership development. They can ensure the leaders work together to support each other, and share ideas, approaches and learning. The incessant representation requirements from the wider system can be prioritised and shared across the group. Equally, a strong collective voice for primary care and the area can be established through a federation (whereas multiple network voices, potentially contradicting each other, is likely to weaken the overall general practice system voice).
Primary care networks are not in competition with each other, and working together through a federation can help meet some of the major challenges they will inevitably face. It does of course rely on trust, and a belief that the federation will operate to serve and support the new networks. It may be that governance changes, such as ensuring there are at least a majority of network clinical leads on the federation board, are needed to establish the future role of the federation in support of networks. But however it is done, it does seem there could be a very important role for federations in support of general practice as we move into the new world of primary care networks.

20
mar
0

The new BMA Primary Care Network Handbook

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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 15th 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.

13
mar
0

How Much Governance is Enough for Primary Care Networks?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The relationship was over.  After a bright beginning things had slowly deteriorated, and now it was time to call it a day.  The problem was we had a house, a car, joint bank account, the works.  We were faced with a choice – get the lawyers in to fight it out, or sit down and work it out ourselves.

Would we have been better sorting out a legal contract at the beginning, so that in the event of this situation arising we would have had a framework to sort it out?

This is the question some practices facing the prospect of entering a Primary Care Network are asking themselves.  Two thirds of the promised new money for general practice is coming via these networks, and that may just be the start.  CCGs and STPs are likely to put nearly all future local enhanced services through these nascent networks.  The fates of each practice within a network will be intertwined.

With this in mind, the temptation is to establish some form of legal contract between the practices.  Yes there is going to be a model network contract, but is it going to be enough?  Networks are going to need every practice to pull their weight.  Would it be better to get them to sign up to both their commitments and, more importantly, the consequences if they don’t meet them?  Won’t that provide better protection for everyone?

Back to the end of the relationship.  We sat down and had the difficult conversation, and agreed who would be having what.  It felt like a better way to sort things out than paying expensive lawyers and asking them to decide.  We would have had to have the conversation anyway, but this way we had it face-to-face rather than through our legal representatives.  I don’t think an upfront legal agreement would have done anything other than breed mistrust from the very beginning and increase the likelihood of legal fees down the line.

If a practice in a network doesn’t pull its weight, doesn’t fulfil its commitments, or doesn’t do what it is supposed to do, all of the practices will lose out.  Stronger legal agreements won’t prevent the need to have the difficult conversation.  Better to focus on the work needed to avoid this situation in the first place.

Three things feel more important than investing in lawyers for practices at this stage:

  1. Build positive relationships. Develop enough trust between practices to be able to have the “difficult” conversation without getting the lawyers (or the CCG, or NHS England, or the LMC etc) in.  Time invested in relationships before these conversations are required will repay itself over and over if it means practices in a network can work through their own challenges and issues internally.
  2. Appoint the right GP network leader. Brokering these conversations is likely to fall to the appointed GP lead of the network.  Building bridges between the practices may well be the key challenge of these new leadership roles, and be much more difficult than the external facing requirements.  Appointing someone trusted by all of the practices will be key to future success.
  3. Get the size of the network right. Smaller may be better.  There has been an initial reluctance in certain quarters to move from pre-existing localities and groups of 70 or 100 or even 150 thousand populations into the new 30-50,000 limits.  There is a sense of safety in numbers in the larger groupings.  But the point of the new size is that it is small enough for everyone to know everyone.  At this size, building trust across everyone is more possible, and the leadership challenge less impossible.

One of the key strengths of general practice has been the family feel of the practices, and the close relationships between staff and with patients.  This is a strength practices should aim to build on as they move into networks, rather than abandoning personal relationships in favour of legal frameworks as a way of reducing risk.  Involving lawyers might feel like it is adding a layer of protection, but the reality is the success of the network will be based on the strength of the relationships, the quality of the leadership, and the ability to have the difficult conversations when they are needed.

6
mar
0

What do Primary Care Networks Have to Do?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

27
feb
0

Who Should Host Your Primary Care Network?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I have talked a lot about needing to start with why and build relationships before you get into the discussion about what form your primary care network should take.  But time is short, and form is also a decision that will need to be made.

First things first.  £1.8bn of the promised £2.8bn coming in to general practice in the next five years is coming through networks.  It is worth spending some time making sure these are set up correctly!

Technically practices sign up to networks by signing up to the Network Contract DES (guidance due out in March).  Networks are not to be legal entities of themselves; the aim is explicitly not to create another layer of governance/bureaucracy.  In signing up to the Network Contract DES practices have to identify, by 15th May, “the single practice or provider that will receive funding on behalf of the PCN” (p27).

The contract goes on to say, in paragraph 4.32, that “It is for each PCN to decide its delivery model for the Network Contract DES.  It could be through a lead practice, GP federation, NHS provider or social enterprise partner”.

But which option to choose? How would a new network decide?  It is worth spending some time examining the pros and cons of each of the options.

  1. Lead Practice

Summary: This model feels primarily designed for those practices already at the magic 30-50,000 population, who wish to become a network in their own right.  The money stays close to general practice, but could be a fast-track to inter-practice disputes where more than one practice is part of the network.

Pros Cons
Allows a single practice to receive/manage all the network funding Funding routed through one practice can lead to tensions between practices
Keeps the funding as close as possible to core general practice Liability for expenditure (e.g. employment of new staff) sits with the host practice
Enables rapid decision making and minimal bureaucracy Limited ability to influence as wider general practice within local integrated care arrangements, or to develop services beyond network boundaries

Key questions to consider:

If the network has more than one practice: How will you ensure all practices have an equal say?  How will you ensure transparency between practices? How will you prevent it feeling like a pre-cursor to a future merger with so much of the funding flowing through one practice?

How will you establish joint working arrangements with other networks? How will you create a strong local voice for general practice with other networks?

  1. GP Federation

Summary: This model feels primarily designed for those practices who already have a successful GP federation in place, who want to use the federation infrastructure to strengthen the ability to deliver against, and maximise the opportunities of, the Network Contract.  It will require a clear accountability of the federation to the networks.

Pros Cons
Creates a GP owned host that will allow equity between practices in a network Given the timescales, is likely only to work where GP federations already exist
Creates opportunities for at scale working beyond network boundaries, e.g. extended access funding is often already routed through federations, development of services to impact the Investment and Impact Fund Federation may have priorities different to those of networks, e.g. delivery of existing contracts
Limited liability for the member practices of employing new staff if employed directly through the federation May feel like the networks work for the federation rather than vice versa if not structured correctly
Potential enabler of strong collective voice for general practice in local integrated care working Potential VAT issues if practices want to second existing practice staff into the federation

Key questions to consider:

How will you make sure the federation is working for the networks, and not vice versa?  Who controls the decision making in the federation?  Do/will the networks have enough of a say?  Is there a willingness among federation leaders to adapt the existing governance to meet the needs of networks?

  1. NHS Provider or Social Enterprise Partner

Summary: This model feels primarily designed for those practices already in some form of partnership arrangement with either the local hospital, the local community or mental health trust, or some other organisation.  Without an existing relationship in place it is hard to see how the level of trust could be high enough for practices to be willing to entrust their funding to them.

Pros Cons
May be able to provide additional services for networks such as estates or HR support Is only likely to work where a reasonably advanced existing agreement is in place between local practices and the host organisation
Large turnover organisations will be able to carry liability and any financial risk the networks want to undertake The size and core business of the organisations may mean the networks and their activities are low priority for them
May enhance ability to recruit and support new staff groups e.g. physiotherapists, pharmacists, where host organisation already employs these staff groups Voice of the networks may get confused with that of host organisation in system/integrated care discussions
May be able to offer synergies with own service offerings, e.g. integrating community and primary care teams Distance of the funding from practices

Key questions to consider:

What influence will the network have on the host organisation?  How will it be able to control how network funding is used?  Does the relationship rely on certain individuals, who may only be around for a few more years?  How can networks ensure they can retain a distinct identity from the host organisation?

Conclusion

It very much looks like different solutions will be appropriate for different areas, and that there is no obvious “best” solution that applies to all.  For single practice networks, or those already in a federation or who have a pre-existing relationship with another organisation, the challenge is probably mainly about adapting their existing arrangements to meet the network requirements.  But the greatest challenge may lie with those nascent networks who are formed of a group of practices, with no federation or obvious organisational link.  For them, the best way forward appears far less clear.

20
feb
1

First steps towards networks

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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

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

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

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

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

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

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

13
feb
1

Primary Care Networks: Start with the right question

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

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.

6
feb
0

The GP Forward View and the new GP Contract: Spot the Difference

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

  1. 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.

  1. 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.

  1. 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.

  1. 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.

30
jan
1

The Obsession with Access is Destroying General Practice

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

If you ask the government what is important about primary care, it is clear there will only be one response: access.  Access is determined to be important to voters, and so it is access politicians care about.  Whatever the cost to general practice itself.

Looking back to 2016, the GP Forward View feels very much like a solution to the strong governmental desire to introduce extended access, despite the crises befalling general practice.  Here is a headline £2.4bn…with the condition you deliver extended access.

Indeed, recent reports suggest a huge investment in recent years into general practice.  This is not what it feels like to practices.  Much of the investment never reached practices, but instead went to extended access providers.  As these providers deliver general practice, it all “counts” as investment in general practice.

The reality is, of course, that the introduction of extended access has made things worse for practices.  The root cause of the workload and financial problems, alongside the inexorable rise in demand from a growing, ageing population, is the lack of GPs.  Fewer GPs means more work for those who remain, plus an increased expenditure on locums which in turn creates a huge financial pressure on practices.  The introduction of extended access simply creates an additional demand for GPs, stripping down further the numbers who can work in core, in-hours general practice.

The pledge to increase the number of GPs by 5,000 was a central part of the GP Forward View.  But despite an increase in the numbers entering training, the numbers leaving has exceeded those arriving.  GP numbers (FTE excluding locums and registrars) fell 3.4% between September 2016 and September 2018.  The pledge to increase access to 8am to 8pm seven days a week, on the other hand, has been delivered.

What, then, do we get in the Long Term Plan?  Yet another access pledge.  “Digital first primary care will become a new option for every patient improving fast access to convenient primary care.  Some GPs are now offering their patients the choice of a quick telephone or online consultation…. Over the next five years every patient in England will have a new right to choose this option – usually from their own practice or, if they prefer, from one of the new digital GP providers” (Long Term Plan 1.44, p26).

So now, in addition to GPs who choose to work extended access hub shifts (convenient, without the pressure and hassle of core general practice), we are going to have GPs who choose to work for “one of the new digital GP providers” (potentially ‘working from home’ for GPs).  Further dilution of a precious and diminishing workforce, all in the name of access.  All piling yet more pressure on a general practice that is creaking at the seams.

Amidst the plethora of documents that have come out already in 2019 (with potentially the most important, the new GP contract, due this week), there is one ray of hope.  Dr Nigel Watson’s Partnership Review did explicitly recognise the pressure access is causing core general practice.  His recommendation 5a states, “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” (p32).  He explains, “Extended access services in many areas are attracting GPs away from practices. NHS England should therefore consider how existing funding for extended access and opening could be allocated through PCNs as they mature, to enable local decision making on managing demand appropriately. This should also support partnerships to feel a greater sense of control and influence over managing the safety of their working day.  It could also reduce fragmentation of services and increase opportunities to improve continuity of care.”

It is not a recommendation, however, that has been picked up in the Planning Guidance or the Long Term Plan.  Whether it will turn into anything remains to be seen, but the priority this government has placed on access to primary care, regardless of the consequences for core general practice, makes me, for one, sceptical as to its chances. However, it is certainly a recommendation fledgling primary care networks would do well to remember as they move forward, as its chances of implementation probably relies on pressure from them.

BMA Council Chair Chaand Nagpaul summed it up well when he said, “There is no use opening the digital front door to the health service if we don’t have the healthcare staff behind it”.  The current obsession with access is dangerous, because it is making a bad situation worse.  A resource can only be stretched so thinly, and it is only a matter of time before more holes begin to show.

23
jan
0

Primary Care Networks are the new black

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

16
jan
0

Guest Blog – the NHS long term plan, a GP at-scale view

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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/

28
nov
0

Making general practice easy to do business with

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Is general practice easy to do business with? The prevailing wisdom of the day is no, general practice is not easy to do business with. One of the big gaps identified in the Five Year Forward View was the one that exists between general practice and, well, everyone else. In a world of integrated care systems the NHS needs general practice to be easy to do business with. It needs general practice to be an active partner in the new arrangements because it recognises integrated care won’t succeed without it.

Being easy to do business with benefits practices as well as the system. It means more resources can be directed into primary care, aligned to the impact this investment will have on the system as a whole. It means general practice not only has a voice, but can shape changes to the system in a way that makes sense for its patients. It means the problems of distance from the community providers and the hospitals can be tackled not via fruitless arguments in a contracting room, but in practical changes that impact how services operate.

Why is general practice not easy to do business with? It is essentially a numbers game. The average hospital serves a population of about 300,000. The average practice serves a population of 8,000. So that is an average of 37.5 practices for each hospital to be doing busy with. It is an unsustainable number of relationships for a hospital to maintain. Community trusts serve population sizes of over a million, exacerbating the problem even further.

Enter general practice at-scale. Much of the drive for general practice at-scale is to solve this numbers problem. If general practice is organised into units of 30-50,000 there are only 6-10 relationships needed for an acute trust to be able to partner with general practice. If it is organised into larger federations of 200-300,000, then this number may be reduced to 1 or 2.

But there is a danger of being too greedy. The greater the distance of the general practice organisation from its practices (i.e. the bigger it is), the harder it is for it to really represent the views of its member practices. And of course with integrated care it is not just about presenting views, it is about changing models of care. If the system pulls the (newly created) general practice lever (in the form of the federation) but nothing happens, all we have really done is add to the complexity by increasing the number of organisations.

Hence the value of at-scale general practice lies in the strength of its relationships with its member practices. I write a lot about the importance of trust between practices and their network/federation leaders, but it is because it is so crucial. If these leaders sit around the integrated care table and cannot commit their practices to anything, and spend their time explaining how complex the general practice landscape is because practices are independent contractors, then the gap between general practice and the rest of the system has not really been closed.

But if these leaders can sit around the integrated care table and make decisions on behalf of their practices, firm in the knowledge that whatever direction they choose the member practices will follow on the basis of their belief and trust in them, it means general practice is, at last, easy to do business with.

21
nov
0

Can you solve The Autonomy Paradox?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

A paradox is, “a seemingly absurd or contradictory statement or proposition which when investigated may prove to be well founded or true.”

Try this one on for size… In order to retain autonomy GP practices need to give up autonomy. Is that absurd or true?

It is, in fact, The Autonomy Paradox!

The first question we need to consider is “why is operating at-scale of benefit to practices?” It is because, the argument goes, costs can be reduced, income can be increased, and new ways of working and new roles can be introduced to reduce workload.

But none of these things can happen without practices operating together as a collective. The group of practices working together “at scale” need to agree to a single way of doing things in order for any of the benefits to be realised.

For example, they all need to agree to move to a single accountant, or they all need to agree to a new paramedic-led visiting service, or they all need to agree to cross-refer their dermatology patients to one of the practices rather than sending them directly to the local hospital. Some practices will gain more than others from each change. One practice may have very cheap accountants, and my gain little or even lose out by the shift to one accountant across the group, but by that practice agreeing to it the group as a whole gains. Equally another practice may have a very low level of visits and so introducing the new paramedic model may feel like it is more trouble than its worth, but by participating the group as a whole benefits. The benefits of individual changes are rarely shared equally.

This, of course, is where difficulties set in. In my work with practices up and down the country, I am yet to go to an area that has introduced extended access without disputes about differential utilisation between practices. There is a deep seated reluctance for any practice to agree to a change that benefits another practice more, let alone one that might create a worse position for itself “for the greater good”.

But for operating at-scale to work, this is exactly what is required. For working together to deliver the maximum overall benefit, practices have to be prepared to make individual decisions for the benefit of the group, and trust that the overall benefit of working together will come to them.

Of course this is not the only option. Practices could fully merge, and then the single entity gains the benefit, rather than them being (differentially) apportioned across participants. But what is the cost of this for the original practice? In this (merged) scenario the practice has given up its independence altogether to become a new (admittedly independent) organisation. But it is no longer in its original state, with the freedoms that brought. The cost of receiving an equal share of the benefits was for the original practices to give up their independence altogether to form a new practice.

As the scale of the required changes grows, so does the problem. At what point, or at what size of practice, do we declare we no longer have independent general practice, but rather a group of (GP-led) corporations running the majority of services? Is this future worth it in order to ensure that at each point benefits are shared equally between practices?

In order to retain autonomy GP practices need to give up autonomy. If practices choose to cede some decision-making to the collective, so that benefits can be achieved at the group level rather than solely at an individual level, practices could retain their independence. They could avoid the need to either merge into larger and larger practices, or reach a dead-end when getting out is the only option remaining.

The choice is not either independence or dependence. Inter-dependence, and using federations, networks and the like to create this, is an option that allows practices to stay as separate units but enjoy the benefits of scale. But it requires practices to give up some autonomy in order to retain overall autonomy.

14
nov
0

How to build trust with practices

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The key success metric for at-scale general practice, the one I would be monitoring most closely in my own at-scale general practice organisation, is trust. Do the practices trust the federation/network/primary care home/insert local name here?

Why? It is because at-scale success, one that is to genuinely support GP practices, depends on practices giving up some degree of individual autonomy to the at-scale organisation. And this will only happen where there is trust. Without trust, practices will work to protect individual autonomy, not give it up.

So how can any at-scale general practice organisation build trust with its member practices? An interesting place to start is Charles Green’s trust equation. The equation is:

Trust = (credibility + reliability + intimacy) / self-orientation

This is summarised in a Harvard Business Review article (here). Credibility is the perception of credibility, and ultimately stems from whether practices think the organisation is honest and truthful, and whether they think what it says can be believed. Reliability is again a perception, of whether the organisation will do what it says it will do. Giving up any sort of autonomy means a practice needs to believe those to whom it is giving up autonomy can deliver on their promises. Intimacy is the willingness of a practice to trust the at-scale organisation with something. This needs a relationship between the two to exist.

But what strikes me as most interesting about this equation for at-scale general practice is that the denominator is self-orientation. This is the extent to which practices believe the focus of the at-scale organisation is on itself rather than on the member practices. The stronger the belief held by practices that the federation or network is primarily concerned with itself rather than its member practices, the greater the extent to which trust is lost.

How, then, can such an organisation reduce self-orientation? What can it do to build confidence with member practices that it is genuinely there to support them?

Create opportunities for practices to speak. Often communication between at-scale organisations and practices is one way. The federation or network will report back on what it is doing, and explain its plans going forward. But what is equally important is to enable practices to talk about what is important to them. Often the best way to do this is for leaders to visit individual member practices with the sole intent of listening to what the practices have to say.

Listen with intent. Creating the opportunity for practices to speak and then taking no action as a result is probably worse than not doing anything. It is simply lip service. The more practices feel you are listening to what they are saying the more they will engage, and the less they will feel you are simply carrying on with your agenda regardless of anything they have to say.

Take responsibility when things go wrong. A clear signal that organisations are oriented to themselves is when they blame others for failure. This might be the practices, the CCG, other federations, the government (the list can go on!). By taking responsibility, and by being transparent, practices can start to see that you have integrity. Avoiding the tendency to blame others shows you are committed to delivery, and that your focus is more on making things work for practices than your own reputation.

Trust is hard to win and easy to lose. Guarding against self-orientation, and actively keeping focus on the needs of member practices is one of the best ways for at-scale general practice organisations to build and maintain trust.

7
nov
0

Guest Blog – It’s time to get the lawyers in!

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In last week’s blog Ben suggested that spending time and money on lawyers whilst developing new federations might be a mistake. But Craig Nikolic, Chief Operating Officer of Together First (a GP federation in Barking and Dagenham) had different ideas. So this week he gives us his take…

Ben Gowland’s blog piece on the Perfect Governance Model for GP Federations hits the spot on most areas and is correct that Federations that overdo “governance” are setting themselves up to become cumbersome and inefficient. Where I disagree with Ben is in the commissioning of professional advice.

For the vast majority of the NHS, the statement “it’s time to get the lawyers in” means that something has gone wrong and it’s often far too late. Most NHS senior managers have only seen lawyers in outright firefighting mode where they’re trying to fix problems, and doing it expensively.

To someone like me who has spent most of their career outside the NHS, this is a strange phenomenon and makes about as much sense as refusing to spend £100 on fire extinguishers then later complaining when you call the fire brigade to stop your business burning down.

A good lawyer or accountant, or even both, brought in early can be a very positive event when you’re doing business transformation. The trick is understanding what lawyers can do for you. For most NHS folk, lawyers are there to help you get over negative legal problems, or to legally threaten someone else, and they’re expensive. On the positive end of legal advice, it can be substantially cheaper to get a lawyer in early than put it off then find out when it’s too late that you’ve got it all wrong.

In Barking & Dagenham, we’re undergoing substantial transformational change and there’s a few areas where we’ve had uncomfortable experience of things going the wrong way because of the standard NHS “gentleman’s agreement” or a vague MoU over a critical piece of our business. We brought in lawyers and accountants to make sure our new plans get it right first time.

I’ll give a few of examples:

  • Take a GP Federation that wants to hold APMS/GMS/PMS contracts yet has GP practices in its area that are corporate bodies, say other APMS practices. Do you know absolutely and beyond doubt how your Federation can hold those contracts and also have the corporate body as an equally represented Federation member?
  • Do you do business with other NHS organisations by MoU? What’d happen if the other organisation said tomorrow “sorry, but that’s it, we’re stopping this deal today and you have no comeback because MoUs aren’t contracts”. That happens far more often than you’d think in the NHS.
  • Could your Federation’s books cope with a substantial amount of delegated commissioning if it suddenly came from the CCG? How could you track the financial viability of each LIS or contract? Are you confident that your cash flow could keep up with the slow nature of centralised NHS payments or payments from other care settings such as acute Trusts?

Getting formal legal and accountancy support on those items is not expensive, the trick is working with them properly. On lawyers especially, work with them, tell them in detail what you want to accomplish and how you’re planning to do it then put the open statement: “tell us the risks in what we’re doing”. It’s your plan, not theirs, you must put the hard work in first. Most NHS people dealing with lawyers give them nothing but vague statements and then say, “tell us how to do it”. You then get lawyers responding in the most risk-averse way possible with a contract that does nothing but lock people into onerous and negative terms. See the difference?

Imagine a GP referring a patient to a Consultant, you’d grumble at a GP just referring on and saying “patient is not well, tell us what to do” and giving nothing else, yet that’s what lawyers dealing with the NHS often get. Most of the money lawyers charge the NHS is spent doing their equivalent of “What do you mean by not well? Come on give us a clue, is it his leg? Maybe his arm?”

We did the positive work with our lawyers, we built a good relationship over overwhelmingly positive items and working through our already very robust plan. We got reassurance that most of the stuff we were doing was perfectly fine and had a legal opinion we could give to Commissioners and others to prove it. We changed track on a couple of minor points to address legal issues we simply didn’t know existed. We now have a clear idea of how to work well with other NHS organisations without having to get into regressive and negative protectionist contracts. Most importantly though, we know for sure that our plans are fit for a very flexible future that could go all the way from staying the same size all the way through to becoming a super-power Federation.

That’s it. Done. A simple, low bill to lawyers and we now have a clear foundation that’ll do us for years, protecting us from most negative events and giving us simple tools to help us do business more efficiently.

For me, that’s a no-brainer and I’d be in dereliction of my duty as a professional senior NHS manager to not take advantage of such an easily accessible resource.

31
oct
0

The Perfect Governance Model for GP Federations

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

One of the problems I have been grappling with in recent weeks is trying to work out why there is no single, universally applicable model of governance that GP federations can adopt. I have seen governance models that have worked really well in one area be a real hindrance to progress in another, and I wanted to understand why.

What has helped me unpick this is thinking about organisational life cycles. If you are not familiar with these, essentially each organisation goes through a life cycle from creation through to termination. People who look at these things have found organisations do not progress through a series of random events, but rather through an expected sequence of stages. These are start-up, growth, maturity, renewal and decline[i].

Different organisations go through these stages at different rates. Some companies like Blockbuster Video and Boo.com (anyone?) came and progressed quickly through to decline, while others like Colgate and Cadburys feel like they have been around longer than most of us can remember. Some, of course, never make it out of the start-up phase.

This helps us understand why the ‘cut and paste’ model of federation governance doesn’t work because the governance needs of an organisation vary according to the stage of development it is at. In a start-up it is generally all hands on deck with everyone (including the board) doing what is needed to get the idea off the ground. During the growth phase the board is more focussed on plans and policies. And as the organisation gets to maturity the focus of the board is much more on strategy, risk management and holding the leader/CEO to account.

This means asking “what is the correct governance for a GP federation?” is actually the wrong question. The right question is “what stage in its organisational life cycle is the GP federation at?” Once that has been established, we can match the appropriate governance to it.

The trap I see many GP federations falling into is failing to match the appropriate governance with where they are in the organisational life cycle. In particular, many GP federations are in start-up – they have developed a shared vision/mission across the member practices, and there are a small number of leaders trying to maintain engagement and enthusiasm while at the same time getting projects off the ground to prove the worth and value of the organisation. But they spend their time investing in lawyers and developing complex governance arrangements that are appropriate for a more mature organisation.

It is hard enough being a start-up organisation. There are so few people trying to do so much, at the same time as having sceptics to convince. The precious limited resource that is the time and energy of the leaders needs to focus initially on getting ideas off the ground and turning them into action, and of convincing stakeholders that this really is the future. Spending it on creating overly complex governance structures at this stage diverts energy from where it is really needed (as well as being expensive!).

Meanwhile, the high performing federations have already been through the start-up stage. They may even have gone through rapid growth. So the governance they now have is of a mature organisation (looking at strategy, risk management and holding the leaders to account). This is appropriate for them now. But it wasn’t appropriate when they started, and simply because you aspire to be like them doesn’t mean that it is appropriate for your organisation now either.

There is no single perfect governance model for a GP federation. But being clear on where your federation is on its organisational life cycle is the best first step you can take to determine what the most appropriate form of governance is for you.

[i]  Lester, D., Parnell, J. and Carraher, S. (2003). Organizational life cycle: A five-stage empirical scale. International Journal of Organizational Analysis, 11(4), p.339-354

17
oct
0

Never mind the models, it’s the mind-set

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Back in the dark mists of time, I used to work in the national emergency care team. Our job was essentially about applying service improvement to improve the delivery of emergency care. As part of the role myself and others would visit many different A&E departments and hospitals. What struck me most about these visits were the different mind-sets of those we visited.

They generally fell into two camps. There were those who were very warm and welcoming. They wanted to show us every part of their system and explain how it worked. They were eager for our feedback, and were keen to understand how they could make it better.

Then there were those who were not welcoming, who would make us wait, and restrict access to the areas they wanted us to see or to a certain amount of time because of how busy they were (i.e. had more important things to do). They were defensive to any reflections made about their practice, dismissed innovations developed elsewhere, and were not open to doing things differently.

We were not there to judge these departments, only to help. But it was clear from the outset which ones were actually open to any help and which ones were closed to it.

This phenomenon of having an “open” or “closed” mind-set is not limited to emergency departments. It is also prevalent in general practice. There are practices who are keen to learn from others, eager to try new things, and who want to find out where they can improve. Then there are practices who will tell you they have already tried everything that is out there, that it “didn’t work” for them, and that it is the system that needs to change, not them.

Possibly the leading international thinker on this subject it Carol Dweck. She talks about an open mind-set as a growth mind-set, and a closed one as fixed. She says,

“A fixed mind-set doesn’t easily allow you to change course. You believe that someone either has ‘it’ or they don’t: it’s a very binary frame of mind. You don’t believe in growth, you believe in right and wrong and any suggestion of change or adaptation is considered a criticism. You don’t know how to adopt grey thinking. Challenges or obstacles tend to make you angry and defensive.”

The tricky part of all of this is that most people and practices will say they are open to new ideas, and that they have a growth mind-set. But saying it doesn’t make it so. Some people and some places maybe were open to new ideas once, but no longer are. Years of relative success breeds a confidence in what you do and how you do it. It creates a mind-set that challenges and difficulties are driven by external forces and that making changes to meet them and learning from others is disrespectful to how they do things and unnecessary.

This is the difficult place that general practice finds itself in. Some practices are open to new ideas and to making changes, and are developing rapidly. But others are not. Their mind-set remains closed. This is where the real challenge for general practice lies. Primary care networks, operating at scale, technology, the introduction of new roles, creating John Lewis style ownership models (etc.) will only help practices if they have an open mind-set, if they want to learn from others, and if they want to make changes.

Creating a new future for general practice is not really about creating a new partnership model. At its heart it is about developing a new mind-set.

10
oct
0

What GP Federations can learn from the RCN

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

It might feel like getting a voice around the table is the hard part for general practice. It is not. It is just the beginning.

There is a salutary lesson for GP leaders from the experience of the Royal College of Nursing. They had a seat around the table of national pay negotiations for the NHS. Important for nurses, to ensure they are represented. But, under pressure from the government to “sell” the negotiated deal to their members they provided what an independent review described as “inaccurate” information to members, and presented the deal in a way “biased towards acceptance”.

When nurses opened their pay packets in July and found they were much lighter than they had been expecting, they called an emergency general meeting. The Chief Executive resigned, and a vote of no confidence was passed, following which the entire council will stand down.

In system meetings, just as general practice will want the hospital and the acute trust to make changes, so they in turn will want general practice to make changes. How does the federation leader, there to represent general practice as a provider, respond? If he or she is too inflexible, the chances of any system changes being realised are minimal. If too flexible, they could end up the way of the RCN.

The job of the leader is difficult. The real work is outside of the meetings. I have written previously about the importance of establishing a mandate with member practices. But this is not a one off event. Federation leaders need a strong, continuous, two-way flow of communication with their member practices. As situations develop keeping practices informed, listening to feedback, and understanding the mood amongst GPs is critical to being able to make the right decision in the meetings themselves.

It is neither possible nor desirable to go back to practices before each and every individual decision is made. Nothing is more frustrating in system leader meetings than individuals refusing to make any decisions without full Board/practice support. The federation leader must understand their practices well enough to know which decisions they can make and which they cannot.

The trap the RCN seemingly fell into was having agreed to something (even if they felt they had no choice), instead of being honest and transparent with their members they tried to “spin” it to make it more palatable. It didn’t work for them, and it won’t work for general practice.

The trust and support of practices, and the ability to maintain this through periods of changes, is at the heart of the leadership challenge. It requires honesty, transparency, and, probably above all else, a relentless commitment to communication. It requires clarity of purpose – of why general practice is around the table and what it wants to achieve. And it requires strength of character, in particular the ability to make unpopular decisions and to speak out when needed (because caving to pressure from above to agree, as we have seen, is a recipe for disaster).

Like I said at the start, getting a seat round the table means the real work is only just beginning…

3
oct
0

Giving the Federation Voice Gravitas

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We’ve all been in a meeting where someone (let’s say Peter) speaks and makes a relatively innocuous point. But then for the next 10 minutes everyone else who speaks starts with “I agree with Peter…”. You can’t help but notice the influence Peter has.

Later on in the same meeting you are listening intently, and suddenly have a flash of inspiration – you can see a way forward for the group. You build up your confidence, and make your point. You were kind of hoping for applause, but would have taken even some acknowledgement. But instead, nothing. The conversation moves on, as if you hadn’t even spoken. A few minutes later, Peter makes an almost identical suggestion to the one you had just made, just phrased slightly differently. Suddenly, we are back into “I agree with Peter”, the meeting swarms behind him, and it is as if you hadn’t said anything. You sit, bewildered, wondering what is going on.

Why is it, then, that some people have such influence in meetings when others do not? It is a really important point for those leading GP federations to consider, when thinking about how to ensure their voice has influence in system discussions.

As a young manager my mentors would encourage me to have more “gravitas”. It was hard to understand what they meant. It is something of a slippery, elusive concept. The word gravitas, according to Wikipedia, is used to describe someone whose words and actions have importance and weight. You know when someone has it or when they don’t, but it is difficult to understand why, or how you get it for yourself.

Part of it comes from positional authority. If Peter was the hospital CEO then some of his influence is a function of his position. In system discussions it is not because he is the boss, but because of the importance of what he represents (the hospital). For federation leaders, this brings us back to the question of mandate. The positional authority is much stronger if everyone in the room knows that you talk for 30 practices, and if you don’t agree with them they can’t go ahead with anything that involves those 30 practices.

Another part comes from relationships. If Peter has a set of good relationships with those around the table, they are more likely to listen to him. If they don’t know who you are, sometimes it doesn’t matter how good your idea is it is just going to get ignored.

But there is more to gravitas than positional authority and relationships. I remember as a federation leader there was one particular GP who wasn’t particularly well liked by other GPs (although he was respected), and who had no positional authority other than as a partner of a small practice. But when he spoke he always commanded the room. If he agreed with what we were suggesting as a federation (which he sometimes did) it really helped us to make the change happen with other practices. If he didn’t, he would articulate why and making the change from there was almost impossible. In the end we would run proposed changes by him to get his input before taking them forward.

His gravitas came from a really strong sense of values about what was right for his patients. His points never felt like a political manoeuvre, but more like an articulation of what was right. He was always consistent. He was always prepared to agree, and he was always prepared to disagree. He was never afraid to speak his mind. And when he spoke, everybody listened.

For federation leaders thinking about how to have a strong voice, this idea of gravitas is an important one, particularly when trying to shift the thinking from how to get a seat round the system table into how to make it a powerful one. Creating positional authority by developing a strong mandate from practices, building relationships with those around the table so they are receptive to what you say, and speaking consistently from a clear value base that determines whether you support or oppose proposals are all components of giving the federation voice gravitas.

19
sep
0

Building Relationships to Strengthen the Federation Voice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We discussed in last week’s blog the importance of federations establishing a mandate from their practices, but that is only half of what is needed. To have influence, federations also need to build relationships with other organisations.

A common misconception is that attendance at meetings is the same as having a voice. It is not. If a GP sits through a meeting and has no impact on the outcomes then general practice has not had a voice. In fact it is worse, because other organisations can point to the fact that general practice was represented, even though it didn’t influence any of the decisions made.

This is not an uncommon situation. Understaffed federations, often reliant on the goodwill of a small number of individuals, are asked to attend a plethora of system wide meetings as the NHS works up a head of steam in its shift towards integrated care. It becomes a case of finding someone to go, and the poor GP who attends sits there, often without a clue what is going on.

The reality is, of course, that while meetings are often the end point of a decision making process, they are rarely the start of it. In a world of integrated care, the starting point is much more about relationships.

I was working in an area where the federation formed a strong relationship with the local acute trust. The Chief Executive of the hospital was supportive of the local GPs. They worked together on creating a primary care front door at A&E. When the federation needed someone to host the employment of the pharmacists to work in practices, the hospital stepped in. Then the CCG put community services out to tender. The hospital Chief Executive and the federation leadership had a conversation and decided to put a (ultimately successful) bid in, in a model whereby the hospital hosted the contract, but looked to primary care to provide leadership as to how it would be delivered in the local areas (which is exactly what the GPs had been asking for).

This change came about not because of what happened in meetings, but because the federation had built a relationship with the local hospital. To have a voice, to have influence, federations need to build relationships.

There are some really important relationships federations need to have in place. The LMC for one. Federations and the LMC need to work hand in glove together to ensure the voice of general practice is as strong as it can be. Practices are not going to trust the federation if the LMC doesn’t.

Other local federations in the same area are also key. Ultimately they are not competitors but collaborators seeking (more or less) the same thing.   Disagree in private, work out a way forward, and agree in public. If general practice is arguing with itself around the integrated care table, the power of any individual federation’s voice will be lost.

And as in the case of the federation who ended up being able to control the shape of community services in their area, a strong relationship with at least one local statutory organisation (whether it is the hospital, or the community trust or the mental health trust matters less) means when the bigger opportunities come along, the federation is in a realistic position to be part of the conversation.

These are the two foundations federations need to develop to create a strong voice: a mandate from their practices; and strong relationships across the health and social care economy. Next week we will explore how federations can turn these foundations into a voice which has impact.

12
sep
0

How Federations Can Establish a Mandate from their Practices

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Vineet Nayar is famous for what he stood for: “employees first, customers second”. He became CEO of HCL technologies and transformed its fortunes. He believed passionately that the firm itself did not add value to customers, but its employees did. The role of the firm was to build trust with its employees and empower them to make the changes that might at first sight appear impossible.

He was transparent about information and about the firm’s weaknesses with his employees in ways most companies would never dream of. He did this to build trust between the leadership of the firm and those who worked there. The firm was not telling its employees the answers, it was being honest about the challenges of the current situation, and enthusing, encouraging and enabling the employees to make a difference to it.

There is a 10 minute YouTube interview with Vineet about “employee first, customer second”. It is well worth a watch. I think it is entirely relevant to federation’s thinking about their role and the mandate they have from practices. What do federations stand for? Is it “practices first, patients second”?   Is the role of federations to transform patient outcomes directly, or to enthuse, encourage and enable practices to work together and do this themselves?

Federations need to stand for something. To be the “voice” of general practice in the new world of integrated care, federations need a mandate from their practices. To gain that, they need to be clear what it is they are articulating on behalf of their practices. They cannot claim to be the voice of general practice without agreeing with practices what it is they are going to say on their behalf.

They will need some form of agreed vision/strategy with their practices. This will be some version of:

  • A strong and vibrant general practice with the registered list as the foundation of local healthcare delivery
  • Service delivery tailored to naturally occurring local populations of c50,000
  • Integrated primary and community care teams at a locality level
  • The removal of barriers between primary and secondary care, between health and social care, and between physical and mental health
  • A greater focus on health and prevention

You will have your own version of this. Whatever it is, the important part is that it is developed with the practices, not for them. But turning this into a mandate involves not only agreeing the what, but also the how – how will any agreements that are made actually be delivered? The lesson from Vineet Nayar is that it is not only ok for federations to stand for empowering, enabling and supporting general practice, it is what is needed because it is practices not federations that will make a difference to patient care. Federations are not around the table to get more for themselves; they are there to ensure practices get what they need to deliver change locally.

The important conversation with practices is to agree the nature of this relationship. The federation will use its “voice” to get the resources, the support, the infrastructure, the tools and whatever else practices need to make changes locally. But it is the practices that will make change happen. Change is done by the practices not to the practices. Ultimately, it is a two-way agreement, each side with its own part to play.

This is how federations can create a powerful mandate from practices, one where what they agree turns into action. This mandate is based on trust, the hard won and easily lost trust federations build with their practices. Without this mandate, even though it might be at the table, the federation does not really have a voice.

5
sep
0

The Voice of General Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

My first executive director role was at a hospital. I was very excited. Finally, I was going to get the chance to be part of the team who would make all the decisions about the running of the hospital. It was all new to me, and I wasn’t sure what to expect.

Some things, however, became clear immediately. When the Director of Nursing spoke (which was infrequently), her opinion did not carry weight and had little influence on the decisions the team made. But when the Director of Operations spoke (which was frequently), her opinion carried a lot of weight and frequently swayed the Chief Executive into decisions in line with what she had said.

In that same role I went to meetings of the hospitals across the local area. The same thing happened there: some hospitals had a much more influential voice than others. It happens everywhere.

The lesson, of course, is that simply being at a meeting does not mean that you have a voice.

General practice is seeking a “voice” around the table of providers who will be making decisions in the post-commissioner landscape of the NHS. GP federations are being established in many places to be the voice of general practice within this arena. But what exactly does this mean? I looked up the definition of voice (the meaning that we are thinking about here):

“A particular opinion or attitude expressed

  • An agency by which a point of view is expressed or represented
  • (in singular) the right to express an opinion”

What particular opinion or attitude are GP federations seeking to express at the integrated care table? This is a more difficult question than you would think. If they are seeking to represent the views of practices, isn’t that the role of the LMC? Don’t they have a statutory role to do just that? What do the practices expect – are they expecting the federation to sign them up to new ways of working, or are they really expecting the federation to be representing the potential delivery of services outside of hospital rather than anything to do with what actually happens within the walls of their own practice?

And what do the other providers around the integrated care system table expect of federations? Do they think the federations are representing what happens in core general practice as well as the delivery of additional services? If the federation only represents the delivery of extended access (or the like) how influential a voice is it likely to have? Possibly more Director of Nursing than Director of Operations…

The aim of integrated care is not to hold meetings where representatives make the case for their individual areas, but rather that organisations partner with each other. This is why LMC representation at this level rarely works, because the other organisations see the LMC not as a partner but more as a trade union. It is hard for an organisation perceived as a trade union to persuade others it is there as an active partner.

So here is the challenge for federations to think through: how will they establish a mandate from practices that will enable them to be confident that when they speak at the integrated care system table they have the support of the practices behind them? And how will they deliver that voice within that arena in a way that influences decisions rather than is ignored? And when faced with making difficult decisions (which they inevitably will be) how will they keep credibility with both the practices and the system partners?

Over the course of the next few weeks I will consider this challenge in more detail. While there are no easy answers, having a clear approach and preparing effectively can reap significant rewards down the line.

29
aug
0

The Independence of General Practice Series – 5

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Throughout August we’ve run a series of blogs where Ben has considered various aspects of the independence of general practice. In this fifth and final blog in the series he asks

Is operating at scale necessary to protect the independence of general practice?

There is something counter-intuitive about the notion that practices would operate at scale to protect their independence. Many GPs resist any notion of operating at scale precisely because of the restrictions they feel it places on their autonomy. The perceived wisdom is at-scale general practice is a step away from independence, not a move towards it.

But is it? I was struck by the tale of the practices in Wolverhampton. Recently a ninth local practice has handed over its list to the local hospital trust there, taking the total population now under the hospital’s control to 70,000. Now, I am not close to what is happening in Wolverhampton but local GP leaders said the GP partners were motivated by financial ‘non-viability’ and workforce shortages, with the move viewed as ‘handing over the problem to someone else’.

One of the practices put this on its website as it announced it was joining the hospital, “Without the help of The Trust we would definitely have left and would have had no option but to close the practice and split our list up amongst other local Practices. The Trust have been able to find us new Partner GPs, a new site and the funding to refurbish it into a modern GP Practice.”  The local practices, it seems, felt like there was no alternative.

I am sure everyone reading this is aware of the pressures currently facing general practice. Those pressures are not going away. There are no new GPs. Demand is continuing to rise. The financial pressures remain significant. At some point, almost inevitably, practices (like those in Wolverhampton) will reach the point where they decide to hand over the pressure of running the practice, to let someone else take on the responsibility, and to simply focus on the patients in front of them.

In a period of sustained pressure on general practice, where salaried doctors are increasingly earning more than the GP partners, more and more practices will reach this ‘enough is enough’ point. And if the local hospital, or community trust, or whoever, offers to take on the responsibility, increasingly practices will make the decision to trade their independence for the relative security and simplicity of salaried life.

If we take the practices in Wolverhampton back 3 or 4 years, would they have made the same decision then? Could they have envisaged then that things would get to the point where this was the choice they would make? And if they had known this would happen would they have chosen to do things differently?

But what could they have done? Well, the opportunity that practices working together (“operating at scale”) presents is for practices to support each other, and to work together to tackle the workforce, demand and financial pressures all are experiencing.

Here is the irony: practices resist operating at scale in the name of keeping their autonomy, but by doing so are keeping themselves on a track that is taking them to the ‘enough is enough’ point when they will hand their list over to whoever will take it. The status quo is unlikely to remain an option for much longer. However counter-intuitive it feels, it is choosing to work together with other practices that is most likely to protect the independence of general practice.

22
aug
0

The Independence of General Practice Series – 4

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Throughout August we’ve been running a series of blogs dedicated to the independence of general practice. In this fourth blog Ben looks at why independence matters.

At-Scale General Practice Must Stay Independent

The BMA has found GP practices with a higher CQC rating earn more income. My PhD wife regularly pulls me up for mistaking correlation with causation, so I wonder whether outstanding practices earn more income (i.e. the cause is that they are outstanding), or whether they are outstanding because they receive more income (i.e. the cause is that they receive more income)[i].

More research is required to test these hypotheses, but my money would be on the former. I know many areas where the opportunity for income is equal across practices, yet the better practices earn more (through better recovery of QOF income, through delivery of a wider range of enhanced services, and through private income streams).

So in the independent world of general practice, the practices that provide a better service to patients earn more money, while the less well run practices earn less. Independence, of course, means there is no bail out. The risk sits squarely with the GP partners as business owners. Compare this with those leading statutory bodies, such as CCGs. They will earn the same amount of money regardless of how well the CCG does. Salary is not linked to performance. There is no meeting with the accountant where the slow realisation descends on all of the partners that they are going to have to take a pay cut. Instead the CCG goes into deficit and money is spent on management consultants to “help” the CCG get back into balance.

I was fortunate enough recently to spend some time learning about how the system of general practice works in New Zealand. There, a key component is that each practice is part of a network. These networks are not statutory bodies. They were formed by practices nearly 30 years ago, essentially as a protectionist manoeuvre by practices, and their purpose is to strengthen and improve general practice.

The great thing about non-statutory bodies is that they cannot be abolished or reorganised. While in this country we have seen PCGs, PCTs and now (probably) CCGs come and go, in New Zealand over the same period the networks have been constant. They have been able to adapt and thrive over that time, and provide better and better support to their member practices. Indeed, the government has even channelled the contracts for practices through the networks, enabling the networks to take on the role of improving quality across their member practices.

I was the Chief Executive of Nene Commissioning, one of the leading practice based commissioning groups. We were a non-statutory body, but we worked with the PCT, with our member practices, and with many others to drive some impressive innovations across the system. With the advent of CCGs we transitioned into a statutory body. There is no doubt in my mind that becoming part of the NHS system, hounded by layers of hierarchy and regulation, strangled the innovation out of the organisation. It is precisely because CCGs are statutory bodies that ultimately they have not been able to fulfil their promise.

Meanwhile the networks in New Zealand have thrived and continued to innovate. Pinnacle, one of the leading New Zealand networks, has developed an improvement programme for its member practices. It funds it itself, it tests it on practices that it directly manages (the equivalent of our APMS contracts), and is working with its members to make them fit for the future. Not because it has to, not in response to a government initiative, but because its role is to strengthen and improve general practice. It only answers to its member practices, and because it is independent it cannot be abolished or reorganised.

This is an important lesson for us. Moving to at-scale general practice in many areas is the right thing to do. But finding ways to do it that maintain the independence of general practice, and the independence of any at-scale organisations it creates, is absolutely critical. Independence rewards success, and penalises failure. It fosters and encourages innovation. Most important of all, it creates stability and strength for the long term.

[i] My wife informed me after reading the blog I had missed out a third option: that there might be other variables affecting both results. I have vowed never to do a PhD.
15
aug
0

The Independence of General Practice Series – 3

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

This is the third in a five-part series of blogs discussing the independence of general practice. This week Ben looks to the Nigel Watson-led review of the partnership model and considers the possible threats this poses to that independence.

Why the review of the GP partnership model makes me nervous

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.

8
aug
0

The Independence of General Practice Series – 2

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

This is the second in a series of five blogs where Ben is considering the issue of independence in general practice. This week he looks at the distinction between statutory bodies and independent contractors and asks whether the difference is of any consequence.

Can independent contractors be trusted?

During the 2017 Christmas holidays, when you would have thought attention may have been focussed elsewhere, there was something of a debate as to whether organisations that are not NHS statutory bodies, but rather ones that contract with the NHS, can be trusted.

The debate focussed on the pre-cursor of the new favourite (Integrated Care Systems) which was Accountable Care Organisations (remember them?). For example, Dr Phil Hammond, a doctor, radio presenter and NHS commentator, said,

“I don’t think Accountable Care Organisations can be set up in the NHS without legislation stipulating their governance. They need to be statutory bodies to be properly accountable for the quality of care they deliver.” (via Twitter, Jan 1st)

Unfortunately, this debate brought the position of both GP practices and GP federations under the spotlight. If this is true for Accountable Care Organisations, is it not also true for GP organisations?

There is a fine line between being in the NHS and working with the NHS. Back in 1948, amidst the protracted negotiations required to start the NHS, a deal was brokered whereby GPs would not become salaried employees, but rather remain independent, providing services via a national contract with the NHS. This means GP practices provide NHS services, but are not NHS organisations, and “independent contractor” status was born.

Does the distinction between a statutory body and an independent contractor matter? At first it mattered little, but times have changed since 1948. In the 1980s the Conservative government privatised some of our national industries, including steel, railways, airports, gas, electricity, telecoms and water. Although the NHS survived the cut, the purchaser provider split was introduced in 1990. Ever since, fears have remained this was the first step in a plan to privatise the health service, and anything not a statutory NHS body is treated with suspicion.

Over 25 years later, we now approach the end game of the purchaser provider split, in a strange closing manoeuvre whereby the Health and Social Care Act of 2012 seemingly opened the NHS up to more competition, but in practice the NHS itself has closed competition down with a focus on integration through the Five Year Forward View. Fears that accountable care organisations were a Trojan horse to enable the privatisation of the NHS led to their re-badging as integrated care systems.

At some point these integrated care systems will take on a population budget. It seems that rather than allow them to do this as “independent contractors”, the government is prepared to legislate to enable new types of statutory bodies to be created.

Where does that leave general practice? Is the current review of the partnership model an attempt to shift general practice from independent contractor into some form of statutory body status? Are the new, semi-mandated GP networks the first step towards groups of GP practices as statutory bodies? Will the public tolerate at-scale GP organisations that are not statutory bodies, or will the anti-ACO sentiment shift its focus towards federations and the like?

The currency of the new world is trust. People trust their GP, more than they trust their local NHS organisation, and much more than they trust national (statutory) NHS organisations. Being a statutory part of the NHS won’t make the public trust GPs any more. Our experience of CCGs should at least teach us that. My sense is the benefits of being independent (to GPs and to the delivery of health care) outweigh the costs and challenges.

GP practices know it is not the technical difference between an NHS statutory body and an independent contractor that matters, but rather what they do, and the trust they build with the people they serve. The same will be true for at scale general practice organisations. And for integrated care systems. Ironically, it is the relationships integrated care systems develop with their local (independent contractor) GPs that may determine how much their local population eventually choose to trust them.

1
aug
0

The Independence of General Practice Series – 1

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Ben Gowland introduces an exciting new series from Ockham Healthcare:

“In the last couple of years I have written a few articles about the independence of general practice.  The current review of the partnership model being carried out at the behest of government, which is considering what has been the bedrock of general practice for so many years, will inevitably have to consider the issue of independence.  This prompted me to bring together and update what I have produced so far, along with some new thoughts, to create an autumn series of articles on this topic.  Over the course of 5 articles throughout August I will consider the threats to the independence of general practice (from within general practice, from the wider system, and from the review itself), reflect on its importance, and identify what might be needed for it to be preserved.”

In this first blog Ben considers the impact that fewer and fewer GPs choosing to become partners will have on the independence of general practice:

Without GP Partners General Practice will lose its Independence

For me, one of the biggest strengths of general practice is its independence. It contracts with the NHS, but is not part of the monolithic NHS structure. For some this may feel like a technical difference (after all GP practices can still access the NHS pension, and they are funded with taxpayer money) but for someone who has spent 20 years working in the NHS like myself the difference feels much more fundamental.

GP practices are bound by the terms of their contract with the NHS. But within the boundaries of those terms they are free to innovate, make changes, and take whatever decisions they want to improve care for their patients and the working lives of their staff. This is in stark contrast to NHS organisations that are bound by NHS-wide restrictions, ways of operating and approval mechanisms that often stifle innovation and directly impact on culture.

It is now widely accepted that GP practices require more money – whether they are funded directly or through a contract. Moving away from the independent contractor model is not an answer in itself to the challenges facing practices. It will not solve the problems of inadequate funding, insufficient GPs, or growing workload. Independence is not a cause of these problems, but rather is the only reason GP practices have been able to continue the way they have despite the current pressures.

Yet, sadly, the independent contractor model is teetering on a knife’s edge. I visited a practice recently that a year ago was a relatively stable, well-run, 4 partner and 7500 population practice. Within the space of two weeks two of the partners resigned. One was retiring, and one was emigrating to Australia. A few weeks later a third declared they were also resigning as they wanted to become salaried. This left a single GP, who had neither the skills nor the desire to be the sole partner of the practice. She wrote to the CCG informing them of the situation and declared that if a solution was not found she would be forced to hand back the list.

This scenario and others like it are being played out throughout the country. The inability to recruit GP partners is rising to the top of the challenges facing GP practices today. Every resignation of a GP partner creates panic within practices, a sense of being trapped, and a fear of being the one left carrying the costs of closure.

The recent push to secure 5000 new GPs, whilst unlikely to be achieved, has brought new GPs into the profession. But many of these GPs are choosing part time or portfolio careers. The competition for new GPs is pushing up the pay for salaried GPs. The new extended access and A&E based services provide well-paid, flexible alternatives for new GPs, further increasing the challenges of recruitment for practices.

The risk is that, unconsciously, we are creating a system that rewards salaried GPs and punishes GP partners. The number of “zombie practices”, where the salaried GPs earn more than the partners, is reportedly on the rise. By not intervening, general practice as a profession is risking its independence. Without GP partners, there are no businesses that can deliver against the contracts, no practices as we know them today. The NHS will have to directly deliver the service. Once independence is gone, it will never be regained.

I do not believe GPs, even new GPs, by not choosing to be partners are choosing for general practice to relinquish its independent. But I believe that is exactly what is happening below the surface, unnoticed; not as a conscious decision or policy intent, but as an unintended consequence of the way the system now operates (“every system is perfectly designed to get the results it gets” etc.) We have not paid this dilemma enough attention, and must take urgent action before it is too late.

Nigel Watson is leading a review of the GP partnership model. My sense is we need to make becoming a GP partner more attractive. We must provide more training and preparation for GPs who do want to take up the challenge of becoming a partner. We must cherish the independence of general practice, and help the future generation of GPs understand not only the freedom it provides but also what will be lost without it. With or without the review, unless we take action now, general practice will lose its independence.

25
jul
0

Funding GP Networks

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The general consensus appears to have fallen on integrated care systems and primary care networks as the way forward. CCGs have been instructed to encourage every practice to be part of a primary care network, which are to cover populations of (roughly) 30-50,000, and as a result a plethora of these new entities are now developing.

Here is a question: where should the funding for the management of these primary care networks come from?

We may not be convinced that another layer of management in the NHS is what is needed, but if the mantra of the day is primary care networks, and the point of them is to enable core general practice to partner effectively with other providers within an integrated care system, then some management function is going to be required.

What are the options?

1.Use the management margin gained from the delivery of additional services.

Traditionally this is how GP federations have made themselves sustainable. In some places this is the assumed mechanism for developing the management funds for these new organisations. The problem is that the networks are expected to represent the delivery of core general practice, not simply the delivery of the (small) range of new services they may provide. This method creates an incongruence between what the network does and the voice it is supposed to have. It also serves to inflate the management costs they have to charge for any service delivery, which is likely (at some point) to make them uncompetitive.

2.“Investment” by GP practices.

In this model GP practices chip in anything up to £2 per head of practice population. This ensures the network function has a clear sense of ownership from its member practices, and that it speaks on their behalf. The challenge comes here with the underfunding of general practice in recent years. Establishing the networks becomes another drain on GP practice resources, at a time when many practices simply do not have the spare financial capacity. As a result, many practices will choose to pass when the opportunity to directly fund the new networks comes along.

3.GP Transformation Funds.

The GPFV is investing a considerable amount of funding to enable “transformation” in/of general practice. Some STP areas are using the transformation funds to support the establishment of GP networks with appropriate management. This is a sensible starting point, but really is deferring the question of where recurrent funding will come from, rather than answering it (i.e. what happens when the non-recurrent transformation funding runs out?).

4.Additional Funds for the GP contract.

Essentially, a model could be introduced whereby additional funding is given to every practice through their contract, for them to use to fund the management resource required for primary care networks. A similar approach was used in practice based commissioning days when practices in many areas received an enhanced service for practice based commissioning, although then they could choose to use it themselves or pool it to create a shared function.

The benefit of this approach is it ensures GPs retain ownership of the management function because even if it is “pass-through” funding, it comes from the practice. This creates the accountability between the network and the practices that is required for them to be successful. The downside is that local disputes and disagreements make local arrangements hard to pin down and sustain over a period of time – just look at the blood, sweat and tears it took to tie down CCG configurations.

5.Transfer of some CCG management allowance

The final option (that I can think of) is the transfer of some of the management funding that sits within CCGs to these new networks. CCGs as member organisations at some stage in the move away from the commissioner/provider split are going to cease to exist, and the natural replacement for groups of practices looking to work together to improve population health (although this time as providers) is going to be primary care networks, so it seems a relatively logical move. It may also serve to stop the shedding of the huge amount of GP leadership talent that CCGs have uncovered.

This would be a recurrent resource, but the downside would not only be the lack of ownership from practices that this move may generate, but also a reinforcement of an unease held by some GPs that primary care networks are the next iteration of PCGs/PCTs/CCGs.

It will be interesting to see where this ends up. It is important that general practice fights hard against the result defaulting to option 1, which in the end will serve no-one, and put unrealistic pressures on network leaders. I suspect we will find ourselves in some form of amalgam of option 3 (to get things started) and option 4 or 5 – but with the proviso that additional recurrent funds build on and develop whatever was established in the start-up phase to prevent huge backwards steps.

18
jul
0

The Tyranny of Governance

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

There is something difficult, elusive even, about the concept of governance. It should be straightforward. According to the universal fount of all knowledge (Google) the definition of governance is, “the action or manner of governing a state, organisation etc.” Yet somehow in the NHS, governance has drifted into becoming a stick managers wield over clinicians to drive compliance.

Am I overstating it? I am not sure. The first time I really saw evidence of this was when CCGs were first formed. Keen, eager and green, groups of GPs worked together determined to use NHS money to make a difference to local populations. But then these fledgling organisations were subjected to an “authorisation” process, where the focus was on governance and the ability of CCGs to operate as stewards of public money.

Whatever your views on the rights and wrongs of the authorisation process, the result of it was that it sucked the life and spirit out of nearly all of the CCGs. The model constitution, non-executives, multiple committees (etc. etc.) all contrived to create organisations too unwieldy to make any real change happen, to diminish trust between the organisation and its member practices, and to sap any sense of organisational pride or identity.

Last week we published our four step guide for practices working at scale. The real point of this was to encourage practices wanting to work at scale to think about why they wanted to work together and what they wanted to do before getting bogged down in questions of governance.

Don’t get me wrong, governance is important. But it is not more important than having a clear purpose for the at-scale general practice organisation, or more important than working out the guiding principles that will determine how the organisation will operate (its values). It is not more important than building trust between the new at-scale entity and the member practices, or more important than achieving the goals the organisation has set itself. Focussing on these things makes good governance an enabler, rather than governance existing for governance’s sake.

In the days when CCGs were being established, the key cry from practices was that it “did not become like the PCT”. Now the concern from practices about the development of new at-scale general practice entities is that they “don’t become like the CCG”. Yet the pressure “to have good governance” is often forcing some of these newly-emerging organisations down the same route. This is the tyranny of governance.

But things can be different this time. The cycle can be broken. At-scale general practice organisations are not statutory bodies in the same way that CCGs are. They do not have to hold population-based budgets (which will take them down the CCG route), and it is perfectly feasible for them to partner with other organisations (with the required governance) to enable that to happen. They can be whatever the member practices want them to be.

This means there is no ‘right’ model of governance for them. There is no checklist they have to adhere to.   Appropriate governance will depend on exactly what it is they are trying to achieve and do.

New at-scale GP organisations have choices. First they must determine why they exist, then decide what they want to do and the way they want to do it, and finally choose what governance they need to enable them to do the things they want to do in the way they want to do them. Governance in its place is an amazing enabler, but out of place can create a fast track to failure.

11
jul
0

Working at scale – the right way to proceed

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Many practices are considering the benefits of working at greater scale. But, from our experience at Ockham, we see so many approaching it from the wrong direction; by considering what form this expansion will take before even reaching agreement on why they are seeking to get bigger. So we have put together a simple and helpful guide on the steps practices should take to help them successfully navigate this journey.

4
jul
0

Do GPs want to work at scale?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

When I was about 5 years old my brother and I became supporters of Liverpool Football Club. No-one told us we had to. Our parents were not football fans. We did not have to sit in a class to learn about Liverpool Football Club, or pass an exam before we could watch them play. No-one forced us to learn the names of all the players, or their shirt numbers, or the endless statistics from the previous decade. We learnt about the club because we were passionate about it which created our energy and enthusiasm to find out as much as we could, whenever we could, and to pester our father constantly to take us to matches.

Whilst not a football fan, my mother was a catholic. So when we were the same age every Sunday she used to make me and my brothers go to church. We never asked to go, and we went because we had to. We didn’t pay attention, got out of going whenever we could, and spent our time when we were there daydreaming about Anfield and whether Liverpool would win when they next played, as well as generally causing trouble. Eventually, we made life so miserable for my mother that she stopped making us go.

Now I am older, things are not much different. I spend my time doing the things I am passionate about and enjoy doing. There are some things I have to do (chores, shopping etc.), but, as my wife will no doubt attest, I do them as quickly as I can (or try and get out of them!) so that I can focus my efforts on the things that matter to me.

My brother is the same. In fact, we all are. We all want to spend time doing the things we want to do and care about, and avoid doing things we are doing because we have to. GPs are no different. Most GPs want to spend their time in the practice, focussing on making a difference to patients and the things that matter, not doing the things they feel they have to do (but hate) like preparing for a CQC inspection, or attending yet another CCG meeting.

For GPs, where does operating at scale fit in to the spectrum, where “doing it because we have to” is at one end, and “doing it because we are passionate about it and the difference it can make” is at the other?

Looking around the country, it varies.

Some GPs are really passionate about operating at scale. They believe it is key to the sustained future of the profession, to ensuring GPs have a strong voice around the system table and to giving them the best chance of making a difference to the lives of their patients. They seemingly work 24 hours a day on making it happen, putting all their spare time into it, and do so with boundless energy.

But many GPs are doing it because they feel they have to. They feel the weight of system pressure pushing them in that direction, and go along with it because even if they recognise there is some logic to it, their heart is in small, independent general practice. Unsurprisingly, they rarely turn up to meetings, they contribute only what they have to, and are often negative and disruptive.

GPs working at scale because they want to, not because they have to, is what will create the energy to make something great happen. It is what already differentiates those really successful examples of working at scale from the rest. Getting the majority of your colleagues to agree to doing something they do not believe in is storing up problems for the future. Jumping into a federation or a network without even knowing why is a mistake, because you won’t invest of yourself in it.

Spend time on why. Spend as much time as it takes to generate energy for a movement, and only then move forward. That investment of time will repay itself multiple times in the future, because it won’t feel like (your equivalent of) going to church, but instead like going to Anfield!

27
jun
0

Is working at scale just a trend?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Did you ever have a mullet? Regularly wear flares? Decide tattooing your eyebrows was a good idea? I suspect not (or not that you would admit to!). As we all know, things come in and out of fashion, and sometimes there is a real art to avoiding something popular in the moment that later we might come to regret.

A common question I get asked is whether the move to working at scale in general practice is just a trend. The profession has been burnt before (think PMS contracts, fundholding, even CCGs), and it is reasonable to consider whether operating at scale is just another in a list of initiatives that demand energy and time but leave little or no lasting benefit.

It could be a short term trend. It feels like there is pressure in the system on practices to operate at scale, and yet history suggests that changes practices have made because others want them to (like the move to PMS contracts) are often best ignored, because the fickle nature of health policy is such that there is likely to be an opposite policy (PMS reviews) a few years down the line.

When we look at joint working between practices we find the benefits are not always that great: purchasing gains can be limited; extra services can be time limited or put out to tender with little or no margin included; and the additional overheads of working at scale can quickly absorb any financial gains made leaving little or no benefit for the member practices.

Bigger practices can create bigger problems. Communication can be difficult (poor), practices become impersonal and it can feel like the soul of general practice has been removed. Individual disputes do not disappear, and where they are not tackled divorce can follow quickly on the heels of the marriage.

Working at scale itself has now been around for some time. Average practice size has grown steadily from 6250 in 2005 to 7860 in 2017, and according to the Nuffield Trust three quarters of GP practices are now in some form of collaboration with other practices. Could, then, we be heading in the wrong direction? Could working at scale be just a trend, something we will inevitably later regret?

The best way to determine whether something is likely to be a short term trend or something more permanent is to consider the causal factors affecting the change.

There are, as you are no doubt fully aware, some long term trends impacting general practice. Demand is rising. There are more patients, more GP visits per patient, more over 85s and more patients managing one or more long term conditions. This demand is highly likely to continue to rise. The supply of GPs to meet this demand is going down. In the time period from September 2015 to December 2017, the total number of GPs decreased by 720 full time equivalents, despite the national pledge to increase the number by 5000. Less and less GPs want to work full time, or to be partners.

Funding for general practice has fallen from 11% to under 8% of the NHS budget. The promised extra £2.4bn in the General Practice Forward View is hardly touching the sides. The recently announced 3.4% growth for the NHS means no windfall for general practice is coming any time soon. The national policy is towards integration, and providers working together. A 10 year plan for the NHS is expected this year, built on exactly these principles. 7,435 practices operating independently in this environment are unlikely to be able to articulate their need for resources as well as, for example, the 135 non-specialist acute trusts.

Ultimately, working at scale is a reasonable response to these long term trends impacting general practice. Simply deciding to work at scale will not in itself deliver benefits (for all the reasons outlined earlier), but using the opportunities that scale provides to find new ways of managing demand, to expand the workforce and incorporate new roles, to deliver efficiencies and respond to the opportunities that the new integration agenda presents is one of the few things practices can proactively do to meet the challenges they face.

Working at scale is a trend. But it is a trend that is a response to underlying changes affecting general practice. Sometimes working at scale becomes the change itself (which is where problems set in) rather than understanding that its function is to enable the continued challenges to be met. Because the demand, supply, financial and policy changes are all continuing to move in the same direction, my view is that working at scale won’t go the way of mullets and flares, but will continue long into the future.

20
jun
0

It is not the model

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I had butterflies. It was my first day at only my second placement on the NHS management training scheme. I followed the directions I had been given off the motorway and into deepest Salford. The area had long rows of terraced houses interspersed with small corner shops. I passed a group of youths gathered on a corner, hoodies raised, and I hoped they would be out of sight before I had to park and get out of the car. I turned the corner and drove into the car park of an incongruously new and modern building, with immaculate red brick walls and gleaming windows.

It was the Willows Primary Care Resource Centre. It was run by Salford Community Trust; my placement was working with the manager of the new centre. I was excited by the new model of care being implemented here. The centre was based in a district of Salford called Weaste. It was (and I suspect still is) a deprived area, and the centre was part of a community regeneration scheme. The plan was for this centre, which was also home to a GP surgery, to host a range of community facilities, voluntary services and resources, and to act as a “one stop shop” to meet the needs of local people.

An interesting range of services were delivered from the centre. There was a community based leg ulcer clinic, who were using a maggot based treatment for wound care. The Citizens’ Advice Bureau held regular drop-in sessions. There were twice a week art therapy sessions. Physiotherapy and speech and language therapy were provided. Plus there were a whole host of other providers; the space was there, and was available to be used by the local voluntary groups who needed it.

Looking back, and this was over 20 years ago, the model was not hugely dissimilar to the primary care home model. It was serving a defined local population where health and social care needs were closely linked, and it was trying to bring a range of different skills and roles together in one place so that all of the needs of the individuals could be met in one place.

But something was missing. At the time it was hard to put my finger on it. I had a sense of it because sometimes we struggled to attract some of the voluntary groups in to use the centre, and I didn’t really understand why. The locals also seemed to steered clear of the place unless they had a specific reason to attend.

Looking back now, the problem was really one of ownership. The GPs were happy with their new building but by and large left the rest of the centre to others. The district nurses had their base there, but didn’t really interact with the other services running from the centre. Co-location wasn’t resulting in joint working, let alone joined-up care for patients.

The incongruity of the shiny newness of the building with its immediate surroundings meant that rather than local community being proud of it, they were wary and mistrustful. In all the time I was there it never felt like it became the vibrant hub I think was initially intended. Nobody really owned the vision for the place, there was no one driving with a passion to change the lives of the local community. So while the original plans were followed and put in place, it never took off or had the impact that once had been imagined.

What that whole experience taught me is that however good the “model” is, however well we design it, however shiny the building we put it in, it won’t work on its own. It is all about implementation. Not PRINCE-style implementation. But implementation that is about people, about partnerships and about passion. Implementation that is about leadership from individuals who care. And it needs GPs, community teams and voluntary groups to share a vision for the future, a picture of what can be achieved, and to find a way of partnering with the local population to make it happen.

There was nothing wrong with the primary care resource centre as a model. It was a good model. Equally, there is nothing wrong with the primary care home model. But the model will only ever be one part of the story. It takes people who care and who are prepared to step forward to turn a good model into something that will make a real difference.

13
jun
0

Evolution is not mandatory

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I recently chaired a panel discussion that was considering the question, “what will the infrastructure of general practice look like in 5 years’ time?”. What was most interesting about the discussion was the debate the panel had as to whether general practice could evolve quickly enough to prevent itself becoming extinct.

I didn’t expect that either. Most of us would agree with the starting point which is that we expect general practice to become bigger in the next 5 years. However, it won’t get significantly bigger. We might make it to the 20-50,000 population primary care home size, but only because that is what one panel member described as the “mentally capable” next step, i.e. the one that isn’t too far away from where we are now to feel doable. Getting to a 300,000 or even 500,000 population size, one where real economies of scale can be achieved and system leadership exerted, feels like a distant dream in most places because it is too far away from where general practice is right now.

As one panel member explained, the reason anything like this can’t happen quickly is because getting practices to work together is hard work, and takes what he describes as “hand-to-hand combat” – tackling one practice at a time. That is why getting universal population coverage at a scale of 20-50,000 is challenging, and why getting to something bigger than that is simply out of reach.

This pace of change may simply not be fast enough. For two reasons: one, the system wants to drive integration at a greater scale faster than general practice can keep up with; and two, the technological disruption we have seen from GP at Hand is likely to only be the start and it remains to be seen whether general practice in its current form can survive it.

One panel threw in the example of dinosaurs, as a telling reminder that “evolution is not mandatory”. As another said, “all innovation is a generational war, and we know who wins that one…”

Which all then led to an existential discussion about the value that general practice adds. Do we really know what it is? One GP panel member stated he is not clear which patients he adds the most value to – the data simply is not there. The starting point for general practice to move into the future is to prove the difference it makes to people, and then to do more of that.

If the primary role of general practice is the place we take our symptoms to find out what is wrong with us, won’t that at some point in the (near) future get replaced by technology? If it is to act as a gatekeeper to the rest of the system will that role continue to be accepted by the coming generations who demand instant access to everything?

In a 2015 article in the NEJM, Martin Marshall argued that in the future general practice, “will have to get the support they need to continue to provide person-centred care and to deal with the complex and delicate balance among an individual’s health, illness (the perception that something is wrong), and disease (a confirmed diagnosis). General practices will have to facilitate the increasingly important interface between people’s management of their own health and the care that is delivered in partnership with, or by, health care professionals. And they will have to find ways to negotiate the complex trade-offs among the sometimes conflicting expectations and needs of individuals, populations, and taxpayers, whose continuing support for a publicly funded health system is essential for its survival.” N Engl J Med 2015; 372:893-897

I think the point the panel were making is that if general practice develops further as a place that is about compromise, about trade-offs, about individuals not getting the care they really want or need at the time they really want or need it, then extinction of general practice in its current form is a real possibility. Instead, key to the future is understanding, demonstrating and then developing the part of general practice that is genuinely value adding to individuals, their families and their local communities.

You can listen to part 1 of the panel’s discussion here. Part two will be published here on Monday 18th June.

6
jun
0

Why the review of the GP partnership model makes me nervous

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

30
may
0

Practical advice for moving ahead in the new environment

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Even the most successful people and organisations can be caught out when the world around them changes. For Ben Gowland this was brought home by his personal transition from Chief Executive of a small successful federation employing 20 people to a large Clinical Commissioning Group employing over 200. He quickly discovered that the behaviours and approaches that had made him successful no longer worked in the new world. This week, in a “talking blog” he uses this revelation and his years of working with challenged general practices to advise how general practice can move forward in the new environment. Watch his presentation below (you’ll need your sound turned “on”):

23
may
0

A new paradigm for general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The world has changed for general practice. A new, more challenging external environment means the behaviours that have been successful in the past no longer work. A new paradigm is required. New behaviours are needed for general practice to thrive in the new environment.

16
may
0

Who is to blame for the current crisis in general practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Who is to blame for the current crisis in general practice? NHS England? The government? Jeremy Hunt? Workforce planners? The bankers because of what happened in 2008? Millennials, because of their demand for instant-everything? Somebody else?

Whose job is it to sort out the crisis that general practice is in? Is it the same people whose fault the crisis is in the first place? Or is it Simon Stevens, NHS England, Jeremy Hunt, the government, or maybe even the BMA and the national general practice organisations?

These will not be unfamiliar questions for GPs. The injustice of the current situation pushes them into almost constant consideration. But focussing on them does not help individual GPs and practices find a way through the challenges they have to contend with on a day to day basis.

I am sure many readers will have at some point come across Stephen Covey’s book, “The Seven Habits of Highly Effective People”, first published in 1989 with over 25 million copies sold. Within the very first habit that Covey identifies of very successful people (“be proactive”), he introduces the Circle of Concern and the Circle of Influence.

The Circle of Concern contains all those things we focus our energy and efforts on over which we have little or no control, such as the weather, Iran’s nuclear programme, or national debt. For GPs it includes working out who to blame for the crisis afflicting the profession, and considering how much of the soon to be announced additional NHS funding will make it to front line general practice.

The Circle of Influence contains all of those things that we can directly control or influence, such as our actions, our behaviours, our family and our colleagues. For GPs this includes their own individual practice.

The habit successful people have, according to Covey, is focussing their energy and effort in the Circle of Influence where they can make a difference, and not wasting it in the Circle of Concern over which they have little or no influence.

I see this difference regularly in GP practices. The factors causing the crisis are outside of the control of practices. The local response to them, however, is within their control. Some GPs and practices focus their energy on the former, and some on the latter.

The barrier that stops many GPs focussing on the Circle of Influence and the changes they can make is this question of who is to blame for the challenges the practice faces, and whose job it is to sort it out. If it is not my fault, and I am essentially a victim of a system failure, why should I be the one who has to sort it out? Letting go of the unfairness of the situation is far easier said than done.

But the practices who are thriving and doing best in the current environment are those focusing their energy within their Circle of Influence; the ones who are looking at how their own behaviours and actions and relationships can influence and change the current situation for the better. They have not waited to react to changes that others will make at a national or policy level, but have taken things into their own hands.

I recently visited Thistlemoor Medical Centre in Peterborough. The majority of their local population do not have English as a first language, and recruiting GPs has been a longstanding problem. But they have focussed on what they can control, and have created a really innovative model so that instead of relying on Language Line they have trained HCAs recruited from the local community to both interpret and take work off the GPs (you can find out more about their model in an upcoming episode of the General Practice Podcast). The practice is thriving and continues to grow at well over 1,000 patients a year.

In Plymouth three practices merged in 2014 to form Beacon Medical Group, and they created a new multidisciplinary team to manage the on-the-day demand. Since then, in the midst of a really challenging local environment, the practice has grown and continued to prosper.

These are just a couple of examples, and there are many across the country. What they have in common is that local GPs focussed on what they could control not what they could not, and took action. They did not waste their energy assigning blame or hoping for national solutions, but instead channelled their efforts within their own Circle of Influence to change the direction in which they were heading.

Thinking about who is to blame for the crisis in general practice is considering the wrong question. It is operating in the wrong circle. The real question to consider is what can I do, what can I influence, to create a vibrant and positive future for my practice, and to focus all my energy and efforts there.

10
may
0

The impact of the new models of care on general practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“Remind me what they are again” the GP responded. I was asking what his thoughts were on the new models of care. I jogged his memory with a few choice acronyms (MCP, PACS, PCH etc). “Oh those. Hard to say really…”. He trailed off, interest clearly waning, and then visibly winced as he saw the message on his screen indicating the number of patients waiting to be seen.

The concept of new models of care has not really taken off as a driving force for change in general practice since they were first proposed in the five year forward view (5YFV) in 2014. Certainly not within the specific frameworks outlined within that document. Frankly, general practice has been too busy. But some of the principles underpinning the models can be seen in some of the recent developments in general practice.

The relative isolation of GP practices has changed more in the last few years than at any point in its history. Practices are far more prepared to work with each other. We have seen mergers, super-practices, federations and networks proliferate. Practices are also more willing to work with other health and social care organisations, in particular those from community and voluntary sectors. A team based approach is both building resilience and creating a more attractive proposition for incoming staff.

Practices are also far more open to reviewing their governance model. The pressure the partnership model places on individual GP partners has led many to explore other options. There has not been a wholesale move away from the GP core contract in the way that maybe some envisaged when the 5YFV was published, but the desire to retain the “independent contractor” status is no longer as strong as it once was. We may well have only seen the beginnings of the rise of at-scale general practice entities like Modality, Our Health Partnership and Lakeside, as well as acute/primary care collaborations like those in Wolverhampton and Yeovil.

General practice has also shown signs of wanting to tackle the wider determinants of health, rather than simply meeting the ever-increasing presentations of health concerns. There is a dawning realisation that something has to be done to tackle the drivers of demand growth. This sits under much of the primary care home movement, and places like Fleetwood are leading the way in taking this on.

These changes have been framed far more by the challenges the profession is experiencing than by the 5YFV. If I had asked my GP colleague about the impact of the pressures on general practice in recent years, rather than about the new models of care, he would have been much more forthcoming.

But moving away from crisis can only be half a story. We know what we are moving away from, but where are we going? What will be the impact of the new models of care going forward? Do they offer a destination for the journey on which many have already embarked?

The emergence of STPs is the current manifestation of the 5YFV implementation. There is something of a battle around size within STPs, when it comes to integrated care systems. Is the local model to be built around primary care home sized units of 30-50,000 as the focal point of change efforts, driving improvements to health as well as health care in local communities? Or is it to be driven at STP level or acute hospital sized units, with primary care homes operating as sub-localities of sub-localities, languishing at the bottom of the health ecosystem? In many places both are still possibilities, but the window of influence isn’t going to stay open for long.

Much of this depends on voice. There is a challenge for general practice to create a coherent and cohesive voice for general practice as a provider within the STP arena. Some places (like Manchester) have worked hard to create this, but for others the primary care seat is still empty. Without a voice, let alone a unified one, it is hard to see the impact of the new models being a positive influence on the future of general practice, despite the opportunity they represent.

2
may
0

Why is the GP Forward View not working?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

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The Millennial Opportunity for General Practice

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

I am not a millennial. I am not a baby boomer either. To be honest with you, I don’t really know what I am (although apparently I am part of the “lost generation”). How could this possibly matter? Aren’t they just analytical constructs marketing people have developed to try and categorise different age groups?

Broadly speaking millennials are those currently aged 18-35. The first concrete example of the importance of this generation to general practice has been the startling growth of the GP at Hand service, where the practice of offering video consultations grew by 20,000 in 4 months. 85% of the patients joining were millennials.

So maybe there is something in the “millennials are different” mantra after all. This South African analysis resonates:

“The nature of the digital age is to prioritise speed, convenience, and value. The millennial, being digitally native, is exactly the same. This extends from their interactions online to their experiences in healthcare. Doctors do need to look at ways to adapt their practice to meet these expectations in order to meaningfully connect with their patients. From online bookings to …SMS alerts and online calendars, practices already have a multitude of digital solutions to choose from. It is OK that you make changes incrementally, but it is vital that practices start thinking about ways to increase the convenience and speed of the new doctor-patient process.”

Millennials: Getting to know the Patients of Tomorrow, Healthbridge, South Africa

The consensus is that the number of millennials is about to surpass the number of baby boomers, and the differential between the two will grow in the coming years. It is not only our patients but also our doctors who will increasingly be millennials.

Millennial doctors may well be less a product of a technological age, and more a group affected by the junior doctor dispute, the Bawa-Garba case, and training in a system where both they and their senior role models are struggling to cope. It is hardly surprising they feel unsupported, under-valued, and uninspired.

Add to that the growing rejection of the “deferred life plan”, of putting off what you really want to do for what is expected of you, of the idea of working hard until you are 65 to enjoy the benefits later. This is evident in the conflict between a generation of doctors who accepted intolerable conditions when they were training with a new generation who simply will not.

Lucy Cohen, in her article Why Practices Must Engage Millennials, writes,

“As a business owner, millennial, and employer of millennials, I see how different our lives are to that of previous generations. Expect to see them sitting at their desk for set hours of nine to five? Those days are long gone. And if you want millennials to engage with you, then you need to get on board with that idea. We’ve grown up accustomed to communicating and receiving answers almost instantly. So if your (practice) wants to engage with us, we need you to have systems in place to keep us posted on things.”

What I see in all of this is a tremendous opportunity for general practice. The NHS, and its constituent statutory bodies, is not going to be able to respond quickly to the demands of the new generation. The entrenched culture runs too deep. But general practice is far more agile. Individual practices can find ways of letting go of the past and of creating a new, different future that caters for the changing needs of the patients and the staff coming through the doors.

By strengthening the connection with their local community, by valuing individuals over traditional structures and ways of working, and by embracing the opportunity of technology, general practice can become the destination of choice for millennial doctors. It can also harness the growing engagement of millennial patients in their own health to improve health outcomes.

Understanding the changing needs of millennials is important because understanding the needs of our staff and our patients is important. It is an important place to start as we try and shift our thinking from “how do I get out of this crisis?” to “how do I build a sustainable future for this business?”

I will be exploring this issue in much more detail with a panel of experts this month. Watch out for the podcast episodes of these discussions which we will publish over the summer.

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Technology: Opportunity or Threat for General Practice?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The world is changing. We know it. We read books on a Kindle, download films, order just about everything online. Everyone has, and is permanently attached to, a smartphone. The NHS and healthcare has so far remained relatively unscathed, unlike many other industries. But that is starting to change. What will the impact of technology be on general practice?

A number of new reports have come out recently, heralding the changes. One of these, The Promise of Healthtech by Public, describes the rising impact of digital innovators and technology on healthcare.

The report identifies 9 trends where there is significant growth in technological innovation, the areas the report describes as “low hanging fruit”: procurement and productivity; recruitment and training; prevention; winter pressures and supported self-care; Artificial Intelligence (AI) in pathology and radiology; patient safety; mental health; social care; and research. It then maps the growing number of tech start-ups against each of these trends

You may think the report is overstating the pace of change, in its desire to encourage more tech start-ups to follow suit. But I don’t think so, because at the same time the big technology firms, like Apple, Amazon, Google and Facebook, are all moving into healthcare. According to this article published in March in Vox, “The most proven, forward-thinking, and, dare I say, disruptive companies in our country have decided health care should be their next big move.”  So whether it is the healthcare equivalent of Uber or Fitbit, or one (or more) of the more established tech companies, the current (relative) status quo is not going to last long.

Early stirrings are starting to have tremors through primary care. The GP at Hand service led to (mainly young) patients deregistering from their practice to sign up in London. Echo enables online ordering and delivery of prescriptions.

The Public report identifies numerous barriers that have slowed the introduction of technology: lack of clarity about the evidence; fast evolving regulation of digital health products; slow procurement; partial interoperability; unclear data security standards; and limited change management and digital skills. A quick reflection on the reaction to the introduction of GP at Hand within general practice and the size of these barriers becomes apparent.

I don’t think, however, these barriers will stop the tide of digital health development (disruption?) from coming in. Instead, overcoming them may well be the catalyst for greater and quicker advances. The use of blockchain looks set to empower individuals to control their own clinical records, as it can guarantee single ownership without requiring a central trusted authority, which in turn will start to shift power from the NHS as an institution into the hands of patients. The benefits of bringing together health and social media data, of enabling professional and community resources to interact effectively, is at the heart of the argument that is persuading Facebook to enter the health space.

General practice, sitting at the cusp between individuals managing their own health and accessing healthcare when they need it, is ripe for technological disruption. A recent Harvard Business Review article entitled, Virtual Healthcare Could Save the US Billions Each Year outlined it was changes to primary care that could deliver these savings. It says, “Without expanding the primary care workforce, virtual health technologies can augment human activity, expand clinical capacity, and improve efficiency by ushering in a new health care model where machines and patients join doctors in the care delivery team.”

The independent contractor status of general practice means the barriers to entry are not as great as those that exist in the statutory NHS sector. Changes can happen rapidly in a small area and grow, without the need for national decision making. General practice has always prided itself on its ability to respond and act quickly.

The crisis engulfing general practice means the willingness to take risks is much higher than ever before. The incentive for a hospital within the NHS to take a risk on a new “carebnb” discharge option is simply not as great (given the potential for backlash) as for a practice facing financial hardship to try something new, however controversial.

Technology can help general practice become more efficient, but more importantly it can enable much stronger links between practices, their patients, and their local community. Shifting the demand curve is key to general practice emerging from its current predicament. The Public report, describing the trend for the development of technology in the area of prevention, states, “the need for digital solutions for wellness, supported self-care for patients with chronic conditions, AI driven behaviour change models and personalized patient education solutions is only going to increase.”

There is now an opportunity for general practice, given its current crisis, to reinvent itself as the supporter of communities and individuals to actively manage their own health, to act as a guide through the new environment as it evolves, and in doing so to make its own workload more manageable. The paternalistic “gatekeeper” role is unlikely to survive the changes that are coming, but the need for the expert generalist to empower, encourage and enable individuals and their decision making will be greater than ever.

The threat technological innovation presents is to the existing model of general practice. But given it is widely accepted that the current model of general practice is no longer sustainable, and in the absence of any meaningful investment in general practice, the opportunity technological innovation provides for general practice to reinvent itself seems to far outweigh the threat.

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Book Review – Perspectives by Judith Harvey

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

In his latest blog Ben reviews GP Judith Harvey’s latest book “Perspectives: A GP reflects on medical practice and, well, just about everything…”

There are not many non-autobiographical books where you feel like you get to know the author, but Perspectives by Judith Harvey is definitely one.   There is something compelling about getting inside the mind of a doctor, not just as a doctor but as a person, and getting a sense of how they see the world.

Judith Harvey is a GP, a patient, a charity founder, and a unique individual. She is also a very talented writer. “Perspectives” is a collection of articles she has written over a 10 year period. Her articles have been published each week in the National Association of Sessional GPs newsletter, as well as other GP publications. While they were written primarily for GPs, I am not a GP and I still found them highly accessible, as well as insightful, stimulating and challenging at the same time.

Her writing is characterised by her honesty. In “It’s a knockout!” she describes her own experience of having concussion, of how it impacted her ability to think clearly, to work effectively and to sleep properly. In “Sleeping with the patient” we find out why she spent the night sharing a bed with one of her patients. In “Giving up… or stopping?” she shares what the prospect of retiring from clinical practice is like in real time.

As the book progresses you start to sense her underlying frustration with the system, borne out of a deep concern about health inequalities. In many ways, Judith was always ahead of her time: a proud portfolio GP when the voice was not as loud as it is today; writing about the impact of employment on health as a medical student and being summoned to the Dean to be reminded she wasn’t training to become a social worker; to advocating walking (for staff and patients) as a route into cutting the NHS budget back in 2009, well before the social prescribers had moved into town. Her passion for learning from others systems is clear (Judith founded Cuba Medical Link, a registered charity which enabled medical students to travel to Cuba for their electives), as is her frustration that we are not learning more from the system that exports doctors and achieves some of the best outcomes at a fraction of the cost of systems we frequently refer to.

When it comes to dealing with difficult issues, no stone is left unturned. She tackles self-prescribing by doctors (an issue rarely considered by non-clinicians), whether placebos can (and should) be morally prescribed, and the impact discussing an elderly patient’s driving ability can have on the doctor-patient relationship. She talks about the problems of evidence based medicine, about the social pressure put on potential organ donors, and questions whether it is ethical to provide a new face to a healthy person whose face is damaged when the price is premature death.

Ultimately, what I enjoyed most was the sense I was starting to get to know Judith as a person, as someone who loves travel and film festivals and the paintings of Goya, as someone who embraces all of life, rather than choosing to be defined by her profession or one particular aspect of it, and as someone prepared to share some of her innermost thoughts so that we, the readers, can better understand the points she is making, simply because she cares.

Maybe the book would have been even better if it had included more of a biography at the beginning or end. The only thing missing for me was a more direct insight into Judith’s life, into where she has been and what she has done, as a canvas to enrich the colour of the articles.

That said, this book is much more than “a GP reflecting on medical practice and, well, just about everything” as it says on the front cover, which hopelessly undersells it. It is a rare insight into what the world looks like through the lens of someone who is both a GP and a fascinating individual, and as someone who had never previously read any of her articles, I found it captivating.

Judith’s book can be purchased via Amazon here. We will be talking to Judith about her life and career in a future episode of the General Practice Podcast

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mar
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I am a Consumer of Health, and Why this Matters

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

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.

21
mar
1

What does GP at Hand mean for General Practice?

Posted by Ben GowlandBlogs, The General Practice Blog1 Comment

The world is changing. The days of popping down to Toys ‘R’ Us for a present for the kids are over. Last week Toys ‘R’ Us announced it was closing all of its stores. According to toy industry analyst Jim Silver, “They lost online and they didn’t adapt.”

It is not just the toy industry that is changing. It is everywhere. Earlier this month Countrywide estate agents reported significant ongoing financial difficulties. In a statement they acknowledged they had not yet learned how to deal with the challenge from digital property services (such as Purple Bricks).

General practice is not immune to these changes. Lillie Road Medical Centre practice in Fulham, which last year started to offer the GP at Hand video consultation service to anyone outside its area living or working in London, has seen startling growth. Taking up the service requires patients to leave their existing practice and register as an out of area patient. The list size of the practice has grown from 5,000 to almost 25,000 in 4 months, and 85% of registrations have been patients aged 20-39.

The GP at Hand experience means the digital threat to general practice has just become real. The capitated payment system of reimbursement for general practice means losing the younger, healthier patients on the list, and being left with patients who are older with more complex health needs; and could result in income not matching costs. It could well be the final straw for many practices already experiencing financial pressure.

Should these changes be resisted? Are video consultations a “good thing”? In a paper published in the Journal of the Royal Society of Medicine, the team from the Department of Primary Care and Public Health at Imperial College London said that while there is evidence that video consulting is acceptable to patients and offers many potential benefits, at least to those of younger age, its safety and efficacy in primary care currently remains largely untested. It raises concerns that while online consultations may help practices manage demand more easily, it may conversely increase pressure through supply-induced demand, or defensive practices.

In our new society, video consultations are more about allowing patients to access services in the way they want to, and less about reducing workload for GPs. Increasingly, it is patients who are going to set the pace for changes like this. The early results from GP at Hand demonstrate for some there is an impatience to see these changes now. Our recent technology panel ultimately felt the profession would not be able to keep control of the use of technology, and it would be driven by patients, if not now then certainly at some point in the future.

We are only at the start of the “digital journey” in general practice. Technology is evolving all the time. Jim Forrer on the technology panel talked about an app currently in development that can monitor blood pressure, pulse rate, oxygen saturations and respiratory rate through the camera function on a smartphone. Technology will change the doctor patient interaction and the way patients manage their own health. Google and Amazon are entering the health space, using global cloud-based health platforms and data, and this is going to have an impact on general practice.

We may think in a tax funded system based on needs not wants that market forces won’t apply. But the reality (as demonstrated by GP at Hand) is they will, because people will not accept what they perceive to be a second class service when it comes to their health, and will demand that health services evolve in the same way as every other aspect of the world. Resisting the implementation of technology will, at best, be a short term strategy. The risk of that approach is that others will move in to fill the void and the opportunity to respond positively may be lost.

If we can’t stop the march of technology, and given the significant potential financial impact, can general practice survive the changes that are coming? Well, established players in other industries (unlike Toys ‘R’ Us and Countrywide) have. Take the experience of the supermarkets. Online grocery shopping is the fastest growing area in the sector, but it is the major supermarkets who understood the change was coming and set up their own services. While new entrants have come into the market, Sainsbury’s, Asda, Morrison’s and Tesco are the major players. Morrison’s are now building partnerships with those with better distribution networks such as Amazon and Ocado to further cement their place.

The world is changing. GP at Hand is simply the indicator that general practice is not immune to these changes. Right now the onus is on general practice to respond, to respond quickly and to respond positively. Part of the opportunity of the move to scale in general practice is precisely for this, as it enables practices to invest in technology or partner with technology firms, to test and develop its usage and to evolve the model of care. By working together, practices can meet this challenge. The other option, to resist the changes, to pass motions that “more needs to be done” by commissioners and policy makers to preserve the status quo has the whiff of King Canute on the beach, and may leave current GP practice businesses in a position like Countrywide or Toys ‘R’ Us, rather than evolving with the changes like the supermarkets.

14
mar
0

Where is general practice going?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

We all know what general practice is trying to move away from (a crisis), but where is it going?

Anger, irritation, fear, or frustration with the current situation can be a great motivator to get change started, and provide an initial impetus to motivate a practice to take action. But if your only motivation is ‘away-from’ the current crisis, then your attention is consistently drawn to the negatives in your experience, filtering out the positives in the process.

It is also not sufficient motivation for sustainable change. For example, if a GP’s goal is ‘not to be in crisis’ (by their own definition of the term), then they have achieved this goal when they reach the level they decree to mean ‘not being in crisis’. They then lose a significant portion of their motivation so run the risk of dropping back down to a point at which they become motivated by their ‘moving away from being in crisis’ goal again. ‘Moving away-from’ goals produce inconsistent motivation levels which are rarely satisfying at any stage.

Sustainable change requires an element of ‘towards’ motivation as well; a vision of where you want to get to. Creating a vision based on aspirations and positivity and not on barriers or avoidance is both empowering and inspiring.

Where is the vision for the future of general practice? I don’t think it really exists. The GP Forward View seems to be more a public acknowledgement of the challenges general practice is facing while ploughing on with extending access, rather than the development of an inspiring picture of what is to come. So here at Ockham Healthcare (with help from whoever will give it!) we aim to put that right. We want to help build excitement and anticipation about the future of general practice, and to shift the focus from the crisis around and behind us, to an inspiring and attractive future ahead.

To kick this off we are holding a series of interactive sessions with some of the leading thinkers and practitioners in general practice. We are exploring with them some of the key changes they believe will impact the future of general practice. We will distil the key lessons, and capture the learning as a resource to enable GPs and practices to prepare for what lies ahead.

We are going to consider four questions:

  1. How will technology shape the future of general practice?
  2. What will the infrastructure of general practice look like in 5 years’ time?
  3. How will the new models of care change general practice?
  4. What do GPs (of the future) want?

We recently held the first of these panels, to discuss the technology question. You can listen to the first part of the discussion here. We will publish the second part in a few weeks’ time.

What is already clear from our first panel is there are huge changes on the horizon. There is an opportunity for general practice to embrace these changes and use them to create a future that will enable a greater focus on prevention, on building patient ownership and control of their health and their illness, on a new partnership between doctors and patients, and on new treatment opportunities (e.g. the use of virtual reality in pain management).

Finding a way out of crisis is not a plan for general practice. It is the start of the journey, but to ensure it doesn’t peter out there needs to be a vision, a future, a picture of what it will be like. Our aim, starting with these panels, is to help paint that picture.

7
mar
0

The days of CCG Locality Groups are numbered

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

“But we are a membership organisation!” the newly appointed GP Chair exclaimed. “Member practices have to have a voice. We need localities to ensure each GP practice is represented in the decision making of the CCG. Each locality needs its own GP leader, the support of a locality manager and we must pay for the time of a representative from each practice to attend locality meetings”.

The Finance Director looked sceptical. He could see the £25 per patient management costs rapidly disappearing into these localities. “But where is the return on investment?” he countered. “If we fund all of that, the costs of five localities could be nearly half a million pounds a year!”

“This is what will make CCGs different to PCTs” hissed the GP Chair. “PCTs had no route into the voice of GPs and GP practices. These localities will be the engine for clinically-led change and redesign, they will ensure we connect commissioning policies to change on the ground, and make sure we can put the decisions we make as a Board into practice. Without them, we won’t deliver anything.”

And so it was that locality groups started off in many CCGs as the great hope for the future, as the symbol of what could be different. But, as is the way of the NHS, the local freedom promised to CCGs did not materialise, and the voice of localities was overtaken by directives from NHS England, the pressures of the 4 hour target, and the need for centralised financial control. Locality GP Chair roles on CCG Governing Bodies were replaced by clinical lead roles for urgent care and planned care and the like. Localities have continued, GP Locality Chairs are still in place, some even have managers, and practices are still paid to attend meetings, but more often than not these meetings now consist of a one way flow of traffic where teams from the CCG present the latest clinical pathway, referral guidance or QIPP plan to the GPs.

What hasn’t changed are the questions from the CCG finance director as to the return on investment of the locality funding. Now the embattled GP Chair simply knows removing it would be just one step too far in trying to maintain any sense of support from member practices.

So what is next for CCG locality groups? As STPs develop, and the system moves to the introduction of integrated care, it is becoming increasingly unclear what is the responsibility of the local GP federation (as a provider, and the “provider partner” within the developing integrated care system) and what is the responsibility of the CCG locality.

There will come a time when all of the functions of the CCG locality – input into clinical pathways, liaison with practices, redesign of services, representing practices in system discussions – will fall to the GP federation, as power shifts from the old system to the new, from commissioners to partnerships of providers. For now, we are in a transition period between the two.

But a transition period is problematic. Already overstretched GPs cannot be in two places at once. Do we want practices to spend the limited time resource they have on existing commissioning localities or on establishing a strong GP provider voice for the future? Realistically we can’t expect them to do both, and doing so simply limits the capacity to do either. The funding we have invested in the localities is no longer in the right place, and would be better situated within the developing federations.

The extent to which CCGs and general practice accelerate this transition may determine the strength and influence of the GP voice in the new system. Because GPs do not have the capacity for double running in a transition period, it is now time to accept the end of the locality within a CCG and to create a new future for them, and maybe allow them to fulfil their initial promise, within (or even as) GP federations.

28
feb
0

Who Represents Your Practice in Integrated Care?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

What is Integrated Care?

“Integrated care” is the term used to describe provider organisations in the NHS working together to improve care for patients.  The ambition of the NHS, as described in the Five Year Forward View, is to move away from a system of care organised via contracts between providers and commissioners, towards one in which groups of providers are given the budget to work together to deliver outcomes for a local population.

Why is it important for GP practices?

Within an integrated care system GP practices will have stronger relationships with local community services teams, social care, the voluntary sector and even the local hospital.  It will also change the way that GP practices receive (some of) their money.  Whilst the core contract will remain nationally negotiated and paid directly to practices, other income streams such as enhanced services will ultimately come via the new provider partnership (or integrated care “system” or “partnership”).

When will this happen?

There is no national timetable for the changes, as there has been no new legislation to dictate it.  Each area is implementing changes in line with their local STP (Sustainability and Transformation Plan).  Eight areas nationally are acting as pilot systems to “fast track” the introduction of the new system.

The changes have, however, already started, primarily through a push for practices to work together in populations of 30-50,000.  This is evident in the procurement of extended access for general practice, and CCGs have been explicitly asked to “encourage” practices to work together at this scale.

 

What will integrated care look like locally?

There is no blueprint for what integrated care will look like.  The lack of legislation means there is freedom for each area to determine this for itself.  We are currently in the critical period where each area is deciding and agreeing how integrated care will develop locally.  Providers and commissioners are meeting together to work this out, in meetings with a range of titles but that generally include the terms STP or Accountable Care System/Partnership or Integrated Care System/Partnership.

How is my practice represented in these discussions about integrated care?

This is an important question.  I carried out a quick poll on twitter to find out.  The results are below:

Who represents your GP practice in discussions about integrated care? #generalpractice #primarycare

— Ben Gowland (@BenXGowland) February 26, 2018

It is not surprising that practices do not think they are represented by their CCG or LMC. CCGs cannot represent practices, as they are a commissioning body that exists to represent their local population not their practices. LMCs have traditionally been the representatives of general practice. The challenge for LMCs is convincing the other providers they are there as a genuine partner rather than trade union. Integrated care is about building partnerships between providers, not negotiating terms. Some LMCs have stepped up into the role (Tracey Vell in Manchester is the obvious example) but many are simply not able to.

This essentially leaves federations (where they exist) to represent their practices, unless practices are of a size (so called “super practices”) to represent themselves. Some federations have been reluctant to take this on, because their relationship with their members is not one where they feel they can speak on their behalf. Some areas have not included GP federations in the meetings about integrated care. Whatever the reason, the absence of a federation around the table means that many GP practices are not currently represented in these important discussions.

What happens if no one represents me?

There are (at least) two consequences of practices not being represented in discussions about integrated care. The first is that general practice, as the provider of by far the largest number of patient contacts, has no voice in determining what the local integrated care system will end up looking like. The second is that acute trusts, community trusts and other large provider organisations will have the greatest influence on how care is organised and how local funds are allocated between providers in the future.

Why is no one asking how I want to be represented?

The representation of general practice is difficult because of the large number of practices, and because it is not a contract negotiation but a building of relationships between providers. It falls to general practice to organise itself so that it can be represented effectively and build relationships with the rest of the system. There is no incentive for other providers to take on this responsibility for general practice. Tracey Vell talks about how she had to fight to secure a place for general practice around the top table making these decisions in Manchester.

How can I ensure I am represented?

Practices need to do two things:

Establish who (if anyone) is representing you in local integrated care discussions. If it is no one, agree with the other local practices who should be representing you, and then push for this to happen.

Create an explicit agreement with this organisation to establish what they can and cannot agree on your behalf, and what requires further discussion and debate with you directly. Don’t make their job representing you impossible, and ensure they have a strong mandate so they can have a powerful voice with the other providers around the integrated care table. Agree the feedback and communication mechanisms to be put in place between the discussions and the practices, and review them regularly.

Who represents your practice in integrated care?

In summary, it is of critical importance for the future that general practice is represented, and represented well, in the local discussions that are taking place now about integrated care and how the future system will be organised. It is up to each practice to ensure they are being represented, and for practices to work together to empower and enable those representing them to present a strong and unified voice. For federations it is vital they establish a mandate from their member practices to undertake this role on their behalf.

 

21
feb
0

What is a Primary Care Network?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The concept of “primary care networks” is one of the most confusing I have come across in recent times. This is saying something given the plethora of new acronyms and ideas that have sprung to prominence in the last few years (think STP, PACS, MCP, PCH etc). Here I try and unpick what they actually are.

Primary care networks have something of a mysterious past. They first appeared in NHS England’s update last year on the Five Year Forward View, where they claimed they would,

“Encourage practices to work together in ‘hubs’ or networks. Most GP surgeries will increasingly work together in primary care networks or hubs. This is because a combined patient population of at least 30,000-50,000 allows practices to share community nursing, mental health, and clinical pharmacy teams, expand diagnostic facilities, and pool responsibility for urgent care and extended access. They also involve working more closely with community pharmacists, to make fuller use of the contribution they make. This can be as relevant for practices in rural areas as in towns or cities, since the model does not require practice mergers or closures and does not necessarily depend on physical co-location of services. There are various routes to achieving this that are now in hand covering a majority of practices across England, including federations, ‘super-surgeries’, primary care homes, and ‘multispecialty community providers’. Most local Sustainability and Transformation Plans are intending to accelerate this move, so as to enable more proactive or ‘extensivist’ primary care. Nationally we will also use funding incentives – including for extra staff and premises investments – to support this process.”

I remember reading this last year and thinking that it looked anomalous, out of kilter with the prevailing rhetoric of supporting GPs to manage their way out of the current crisis with the promise of extra resources and extra staff. They had not featured in the GP Forward View, where you would expect such a dramatic change for general practice to take centre stage, or even before that in the Five Year Forward View.

Maybe there had been a mistake, some sort of internal breakdown in communications within the towers of NHS England. But no, in an article in GP Online from March last year, NHS England’s Director of Primary Care Dr Arvind Madan said of these networks,

“This now becomes the new delivery scaffolding across the system. And it may be how they organise themselves in terms of access, and population and place-based care, and how they will be meaningful neighbourhoods for services to patients in terms of the offer they get too.”

But then all went quiet again on the primary care networks front. Despite the boldness of the earlier claims, nothing was seemingly happening to make these stated ambitions a reality. Efforts focussed on supporting practices through clinical pharmacists, resilience support and the like.   Until, that is, the recent planning guidance was published, which mentioned “incipient primary care networks” (like they are even a thing) and CCGs were told to “actively encourage every practice to be part of a local primary care network”.

What should we make of this? What is a primary care network? I can imagine CCG leads reading the words in the planning guidance and scratching their heads at what exactly it is they are being asked to do.

The use of “primary care network” seems to have appeared because learning from the vanguards demonstrated that for accountable/integrated care systems to work, they require general practice to be joined together into populations of 30-50,000, as the building blocks of the new system. This joining together of practices, how it happened and what it looks like is very different within each of the vanguards, although was consistently borne out of a huge investment of time, relationships and effort into building and developing trust. The term on its own, however, merely describes the end-state.

It also appears to be a term used to retrospectively fit the move in general practice towards operating at a greater scale into a policy direction. According to NHS England the “routes” to primary care networks include “federations, super-surgeries, primary care homes, and multispecialty community providers”. All very different things. Yes, they all involve previously separate GP practices working together, but they cover a very broad spectrum of what that means in practice. The term primary care network is seemingly used as a generic descriptor of where different areas who have embarked upon a journey of practices working together have arrived.

Herein lies the complexity. A primary care network is not an actual thing that can be defined or described in any detail. This is because the journey for each group of practices that chooses to work together is different and will lead to a wide range of different destinations. For some it will end up in super-practices, for others a federation, for others a primary care home, and for others something totally different. Most confusingly, very few (if any) will end up at a place that is called a “primary care network”.

So let’s not add “primary care network” to the already full lexicon of NHS terminology. Joint work across GP practices is a journey not a destination, and use of the term primary care network pulls focus unhelpfully away from the journey and onto the destination. Let’s hope CCGs do not take their new commands to heart, and that a new industry doesn’t arise in trying to create something that we can’t define.

14
feb
0

Guest Blog – My GP by Sarah Smizz

Posted by IanBlogs, The General Practice BlogNo Comments

The following Blog was previously published by Sarah in a series of tweets (@smizz) and is published here with her kind permission. Thanks Sarah!

Ah, my GP is flipping amazing. I can’t explain how good it really is to have someone who knows you & your medical conditions & what matters – someone who just, like, knows this without ever looking back at the records. Someone who sees a longer & bigger picture.

Sometimes we have disagreements on what the longer picture looks like. In the beginning we’d argue. But he was the only GP at the time who decided to take responsibility for me. Most let me jump from GP to GP. But after every test he’d say, “you do this & you come back to me”

I didn’t know at the time the benefits of having continuous care. I was young & impatient. But now I really get it. Today he instantly knew I had an infection (cuz he knows what my normal is), he prescribed me more stuff cuz of a previous diagnosis to help with current sickness

I whined about my leg being numb esp when I run around 5K & how I wanna run half a marathon & I can’t get past 10K (which is still a HUGE mile marker for me). I said all of my friends can run a (half) marathon & I can’t! & he was like:

“Not all of your friends Sarah. I can’t run a half marathon & I’m your friend.” It sounds proper Cheesy to write but also it felt really genuine.

He asked me about PhD work, what Prague & Japan was like. He told me about a beautiful Japanese animation he watched the other night on Amazon Prime. Even Googled it. I gave him Japanese weird tasting Kit-Kats & he seemed pretty made-up by my gesture.

Then I went on my way, not before he gave me his wise-words full of living life & selfcare wisdom as I went to leave. Dude has his moments as a proper philosophical guru. Then of course, he made sure – as per – that I come back to him to check-in in a few weeks.

GP’s will NEVER be replaced esp by apps. And we need to make sure we take care of them, as they take care of us because they’re the backbone of the NHS and the community. And my GP turns out to also hold me up when I feel like I’m falling down. I know they do this for everyone.

7
feb
2

What the 2018/19 NHS Planning Guidance Means for General Practice

Posted by Ben GowlandBlogs, The General Practice Blog2 Comments

I have always wondered who actually reads NHS planning guidance. It contains really important information, but it is always so dry and impenetrable (deliberately?) that most will rely on “bluffers” briefings from others. So here is my “bluffers” briefing for you (although it is here in full for the brave hearted). There are three key messages for general practice:

 

1.The Obsession with GP Access Continues

Buoyed by the apparent success of introducing extended access across groups of practices at evenings and weekends, the timetable for 100% coverage across the country has been moved up by 6 months to 1st October this year. How much of the heralded 52% of the country that is already covered have permanent (as opposed to pilot) arrangements in place is not known, so expect a plethora of hastily put together procurements to emerge in the coming weeks. These are likely to represent something of a risk to local systems, because if the tenders are not awarded to local practices it will mean a fifth of the GPFV investment going elsewhere (£500m of the promised GPFV £2.4bn is for extended access), and GP engagement in integrated working may suffer as a result.

 

2.The Rise and Rise of STPs and Integrated Care Systems

And integrated working, as I am sure you already know, is now king. The furore over accountable care systems/organisations has led to a renaming as “Integrated Care Systems”. That should do it. More interesting is some of the insight the narrative provides as to how these will operate in future.

In the short term, the power and influence of STPs will rise. They will have “an increasingly prominent role in planning and managing system wide efforts to improve services”. They are expected to develop their management infrastructure. They will be the conduit for capital allocations.

It doesn’t stop there. Over time “we envisage Integrated Care Systems (ICSs) will replace STPs”. These ICSs will have one plan across all their constituent organisations, rather than there being a collection of individual organisational plans. It will be the role of the ICS to assure and track the progress of its member organisations. If an individual trust or CCG has financial or quality issues “the leadership of the ICS will play a key role in agreeing what remedial action needs to be taken”. This is code for ICSs being able to fire the CEOs of the member organisations, the key determinant of where the power lies.

What role this leaves for CCGs (the guidance also all but outlaws the use of contract penalties) is very difficult to identify. Most likely is an acceleration of the merging of CCG teams and the development of a (heavily reduced) “strategic commissioning” functions coterminous with the STP/ICS area.

The development of ICSs will also impact general practice directly. For an area to become an ICS they need “compelling plans to integrate primary care, mental health, social care and hospital services using population health approaches to redesign care around people at risk of becoming acutely unwell. These models will necessarily require the widespread involvement of primary care, through incipient networks”.

Incipient networks? Anyone? All becomes clearer later on in the guidance as CCGs are directed to “actively encourage every practice to be part of a local primary care network, so that there is complete geographically contiguous population coverage of primary care networks as far as possible by the end of 2018/19, serving populations of at least 30,000 to 50,000”.

“Geographically contiguous” is new. I know plenty of areas that have encouraged practices to form networks with like-minded practices, regardless of geographical location. They won’t be happy. It is all very reminiscent of CCG-formation days. And what “actively encourage” means is anyone’s guess. Carrot or stick? Time will tell.

 

3.There is No New Money

Were you expecting any? The message for general practice is essentially investment will continue as outlined in the GP Forward View (and if you missed it, here’s a quick reminder of why the promised £2.4bn is not £2.4bn) – i.e. there is no additional, previously unannounced money. You should still expect the balance of the £3 a head one-off commitment from CCGs between 2017 and 2019, as well as the remaining sustainability and resilience funding to be spent next year (75% by December 2018, and 100% by March 2019).

Financial pressure in the system means “non-elective demand management” is to make up the majority of the CCG Quality Premium scheme. Urgent care will be a focus, but the elective position essentially just must not get any worse. GP referrals are assumed to remain flat (“increase by 0.8% i.e. no change per working day” – whatever that means). And, the guidance confidently states, “there will be no additional winter funding in 2018/19” (there will).

There is a push on CCGs to reduce the routine prescribing of 18 ineffective and low clinical value medicines, and savings against this are “assumed” for CCGs, so expect more pressure here. There is also a national consultation on reducing prescribing “of over-the-counter medicines for 33 minor, short-term health concerns, as well as vitamins and probiotics”.

Finally, there is one other bizarre addition I wanted to point out – a requirement for CCGs to ensure every practice implements at least two of the high impact “time to care” actions. Make of that what you will, but it does seem to highlight the persistent inability of the system to distinguish between top down and bottom up.

 

There you go – the essentials of the planning guidance in one five-minute chunk – now you can bluff with confidence!

31
jan
0

Funding Federations – The Accountable Care Conundrum

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

You will need to bear with me this week as I try and explain why the funding of GP federations is a critical issue for emerging accountable care systems, because moving to a new non-legislated system is (unsurprisingly) complicated.

Let’s start at the beginning. The principle behind accountable care is one of providers working in partnership with each other to redesign services to improve outcomes. By the way, if “accountable care” does become “integrated care” (or some such) in the next few months, it won’t change anything other than introduce a new set of terms for exactly the same thing – it is simply the price (in my view acceptable) we have to pay for non-legislated reform.

For accountable care to work, one of these providers has to be general practice. In an accountable care system/partnership/organisation (delete as locally appropriate) general practice needs to work in partnership with other local providers. The whole concept builds on the registered list of general practice, and of providing services that are joined together and tailored to meet local needs.

But there are lots of GP practices. Too many for local providers to all build a relationship with each of them individually. As a result, someone has to act on behalf of practices. Partnership between general practice and the rest of the system can’t work without this.

Who, then, should take on this role for practices? Well it can’t be the CCG because they have been established to represent the needs of their local population, not of GP practices as providers. LMCs? The main problem here is that practices need someone to partner on their behalf with the rest of the system. While LMCs are good at representing and articulating the needs of practices, partnership has not historically been a strength. They are also often perceived more as a trade union by other NHS providers. So while in theory LMCs are an option, the reality is without exceptional leadership they are not. Which leaves GP federations (in the absence of a local super-practice) as the best vehicle to enable general practice and the rest of the system to partner with each other.

GP federations are experiencing something of a resurgence at present, as practices seek to gain the benefits of working at scale without formally merging. But one of their challenges, as anyone working within a developing federation will know, is that they don’t have any money. The delivery of some services will create a small margin, but this is rarely enough to fund enough more than a skeleton management team.

Here we (at last) come to the crux of the problem. The system needs GP federations to ensure general practice are part of the provider partnership that underpins accountable care. But partnership working and the building of effective relationships takes time, which someone has to pay for. For GP federations the task is doubly difficult, because at the same time as creating new relationships they have to ensure they have a mandate from their practices and keep them on board with any agreements they make. How can the leaders of GP federations find time for this? Should they do it out of goodwill, and effectively pay for it out of their own pocket by giving their time for free? Should the host practices of the emergent GP leaders bear the cost? Or do we expect the member practices of the federation to contribute the ongoing cost of federation leaders both attending system wide meetings and reporting back to them as the accountable care model develops?

None of these are realistic. So the conundrum is how can federations and those representing general practice be funded to ensure that accountable care systems develop to include general practice?

Answers on a postcard. If this conundrum has been solved in your area I would love to hear how. Email me at ben@ockham.healthcare. Next week I will share the responses (if there are any!) and attempt to consider what mechanisms might be available to find a way through this thorny issue.

24
jan
0

What does “being resilient” mean?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The letter I had been waiting for dropped through the letterbox. I had been an “A” student right through school, and my sights were now firmly set on Oxford University. The interviews had been hard to read, but seemed to go ok. I opened the letter. “Thank you for applying to Oxford. After careful consideration it has not been possible to offer you a place”.

I didn’t take it very well. Maybe we are less resilient when we are younger. My (somewhat sulky) response was to decide university wasn’t for me, and I headed off to do voluntary work (“something that mattered!”) instead.

A key part of resilience is described by Bruce Cryer and his colleagues at HeartMath as “releasing the emotional grip” that stress has on us. In their 2003 Harvard Business Review article they describe how to do this, essentially by using techniques to accept the current situation and to develop a new perspective centred on what actions you can take to change the situation.

It took me a long time to do this. After my rejection, I actually did well in my A-Levels, but the following year refused to apply to Oxford again on principle (the principle of, “if they don’t want me, I don’t want them”). I was hanging on to the pain of rejection instead of thinking positively about the future.

Changing our own mindset that things need to and can be different is at the heart of resilience. I think this is the hardest part. In the end, I was sat down by an individual who had become something of a mentor to me. He laid out some different options of what my future might look like. One involved going to Oxford. It did look like the most attractive path… Something seemed to click inside me. It might have taken 18 months(!), but finally I could accept it was me who hadn’t been ready for Oxford (and not vice versa) and I decided to swallow my pride and reapply.

While tenacity and perseverance are key parts of resilience, it is adaptability, and the ability to change mindset, that are more important. Blockbuster Video, Borders Books, Kodak (and many others) kept going for as long as they could when things were tough, but they did not adapt to the new world and the changed environment around them, and ultimately were not able to survive.

I recently had a conversation with Dr Mike Holmes, the newly elected vice chair of the RCGP, about resilience and the importance of it for GPs right now. In echoes of the HBR article, he identified three elements to GP resilience: pragmatic optimism; making do with what you have while making things better; and allowing yourself to think differently.

There are opportunities and new ways of working that can help general practice. Mike Holmes outlined some of these in our conversation. The hard bit for many GPs, as for anyone in a difficult situation, is letting go of the unfairness of what is happening and shifting into the “pragmatic optimism” that Mike describes.

Some GPs and practices have not yet been able to make this shift in mindset. Some will never make it. My life was probably changed forever (with a lot of help!) by shifting my focus from unhappiness with my rejection, to taking action to remedy it. I was accepted into Oxford at the second time of asking. Changing the direction of our lives starts with ourselves, with us releasing the emotional grip our current circumstances have on us, and changing our focus from causes and blame to our response and what we can do about it. This is being resilient.

17
jan
0

Is General Practice Responsible for the pressures in A&E?

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

Well what do you think? Is it? It may well depend who you are. If you are a GP you are unlikely to think so, but as a hospital Chief Executive, who has heard all about the workload and workforce pressures general practice is under, it is easy to draw the alternative conclusion.

But correlation, as my PhD wife constantly reminds me, is not the same as causation. The fact that general practice is struggling with workload pressure at the same time as there is rising demand in A&E only means the two are correlated. It doesn’t necessarily mean one causes the other. And so it is that research was published this week in the British Journal of General Practice looking at the factors affecting emergency department attendance. They found (drum roll),

“…the burden of multimorbidity is the strongest clinical predictor of ED attendance, which is independently associated with social deprivation. Low use of the GP surgery is associated with low attendance at ED. Unlike other studies, the authors found that adult patient experience of GP access, reported at practice level, did not predict use.”

In other words, people are living longer with more long term conditions. This in turn is causing the growth in demand, both for GP practices and A&E departments. The more GP consultations a person has, the more likely (for many groups) it is that they will also have more A&E attendances. Growing demand is the causative factor. Pressure on A&E departments and GP practices are simply correlated.

I am on Twitter (@BenXGowland – the X is actually my middle initial, as opposed to denoting membership of some secret society). You should be too. The GP I most enjoy following on Twitter is Dr Steve Kell (@SteveKellGP). He recently ran a survey (now I recognise I need to be careful here as having preached about the difference between correlation and causation, I know I am going to get stung on the validity of a small sample size, but nevertheless) which found that, of the 48(!) GP practices that responded, 81% had not been asked if they were busy or managing in the first week of the New Year, with only 19% saying that they had. Steve’s concern is that “sadly we value what we measure”.

But simply knowing that a problem exists (there is too much demand, and it is getting worse) does not actually help. Nor does finding someone to blame (whether it is GPs blaming hospitals, or vice versa, or the government, or Jeremy Hunt etc etc). The only real option is to work out what we can do about it (because even if there was more money, which there isn’t, there will never be enough).

Which brings me to another interesting exchange on Twitter involving my friend Dr Kell. His practice is a leading light in the Primary Care Home movement, and he announced on Twitter that his practice had achieved a (highly impressive) 5.5% year on year reduction in emergency admissions. Now that prompted a question in response from Professor Harris of Lakeside Health asking,

“where lies the incentive (other than patient benefit) of GPs working harder/differently/more productively if the £ benefits remain with trusts or CCGs?”

The essence of this question is what is the point of the primary care home, of groups of practices working with other agencies, and managing demand in a different way in the way that Dr Kell’s practice has, if there is no financial return for the practice? His response was that while there is no direct financial return, it makes things better for patients, for staff, and is more efficient.

If we think about this in the context of constantly rising demand, the challenge practices face is how to adapt to meet this demand in different ways. Not because there is a direct and immediate financial benefit, but because the current system is not working, and without change the system is likely to collapse. Everyone working in the system has a responsibility to understand and accept the current realities, and to think and act differently as a result, so that things can improve.

General practice is not responsible for the pressures A&E is experiencing, but it is responsible for adapting and finding new ways of dealing with the demand (like the work being undertaken within the primary care home sites) so that general practice, and the NHS, can continue to manage the rising burden of disease. And if you take nothing else away from this, at the very least you should follow @SteveKellGP on twitter…

3
jan
0

General Practice Podcast – Highlights of the Year 2017

Posted by IanBlogs, The General Practice BlogNo Comments

2017 was a brilliant year for the General Practice Podcast with 50 episodes and well over 2,000 downloads per month. In this graphic (below) we pick out a few of our favourite highlights including some of the most downloaded. We hope you enjoy. The Podcast returns on 8th January 2018 with a brand new episode and then continues with a new, free episode every week. You need never miss out on an episode – why not subscribe to our weekly newsletter here.

Open the graphic here: Podcast Highlights Graphic

 

20
dec
0

What is new in General Practice – Late 2017

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

The end of 2017 marked something of a watershed for general practice. For the first time, the focus seemed to shift away from the crisis general practice is in, to what the future that awaits general practice will be.

And threaded throughout the free content from Ockham Healthcare, we saw glimpses of this future. There was outrage (in some quarters) at the growth of e-consultations – and I spoke to Mark Harmon from e-consult about where we really are currently. We saw the continued growth of the super-partnership and I spoke to Mark Newbold for the latest update from Our Health Partnership as they continue to develop. There was the continued development of new roles in general practice and I spoke to Jenny Drury about paramedics undertaking the majority of GP visits. Jonathan Serjeant and Mark Spencer from NHS Collaborate shared pictures of the future with general practice bringing whole communities together, and we learned of a new style of management leader in general practice from Claire Oatway at Beacon Medical Group.

3 important questions for the future of general practice were identified: Will general practice remain independent? What scale will general practice operate at? What will the role of federations be? In the end it became clear that it is ultimately all going to be about collaboration. The Nuffield Trust produced a report on collaboration in general practice, and federations have come back into vogue. We identified good reasons for practices to join (and not to join) a federation. No longer just needed to subsidise meagre general practice earnings with additional revenue streams, now (and in the future) they will also need to support the delivery of core general practice and to give general practice a voice around the accountable care table.

All the more important because “accountable care” has developed into the potential new game-changer for general practice. Nick Hicks explained what accountable care means, and how an outcomes based contract might actually work. The new ACO contract was published back in August, but the involvement of general practice is more likely to come from leaders getting out and talking to practices. Anna Starling shared lessons the Health Foundation has distilled from the work of the vanguard sites, and Nick Hughes explained first-hand what it is like to lead a federation within a PACS vanguard. We thought about the impact commissioning has had on general practice (overall, not good), and highlighted the importance of a proactive transition from CCGs to accountable care for general practice (here and here).

In the end, we concluded the general practice forward view is not going to change general practice, STPs are not going to change general practice, the revitalised federations are not going to change general practice – it is GPs themselves accepting the situation they are in and making the necessary changes that ultimately provides the only way general practice can move into its new future.

Merry Christmas and a Happy New Year to you all from everyone here at Ockham Healthcare, and I look forward to sharing the continuing journey with you in 2018!

13
dec
0
Here and there

What got general practice here won’t get general practice there

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

There’s a tricky issue at the heart of the general practice crisis. Ostensibly, those working in general practice need to do things differently. It’s tricky because if I accept I need to do something differently, it means I am taking responsibility for the difficulties I am facing, even though the situation is not my fault.

To try and pick a way through this, I am going to lean heavily on a book by Marshall Goldsmith, “What got you here won’t get you there: How successful people become even more successful” (2008). I found this a really helpful book when I was a newly appointed CCG accountable officer. Previously, as a middle manager and running a small organisation, I had always been successful by being very task focussed, by making things happen, and by delivering results. What soon became clear was that this style of managing was not effective when I was the leader of a larger organisation.

It turns out what I needed to do was spend less time trying to force things to happen, and more time communicating what the organisation was about and where it was going, and listening and talking with those who worked in and with the organisation. I needed to be visible, and trust the managers working in the organisation to make things happen, whilst I focussed on making sure the direction and priorities were clear and understood by all.

It might sound obvious, but it was a very difficult personal transition. As Marshall Goldsmith explains, it was difficult because of my personal beliefs. He describes it like this, “One of the greatest mistakes of successful people is the assumption, “I behave this way, and I achieve results. Therefore, I must be achieving results because I behave this way.”

It was hard to change the way I behaved because it had always worked for me in the past. But the world around me had changed, and to be successful I needed to do things differently. The difficult bit was really believing that it was me that needed to change, rather than falling into victim mode and blaming the people and organisations around me. Marshall Goldsmith puts it like this,

“Many people enjoy living in the past, especially if going back there lets them blame someone else for anything that’s gone wrong in their lives. That’s when clinging to the past becomes an interpersonal problem… When we make excuses, we are blaming someone or something beyond our control as the reason for our failure. Anyone but ourselves.” 

I remember the point at which I realised it was me that needed to change. We had been a really successful practice based commissioning group, but had struggled in the transition to becoming a CCG. It was easy to dwell on the successes of the past, and blame the challenges we were facing on others. But ultimately that wasn’t going to help. For me it was facing the feedback from our CCG authorisation process (remember that?) – it was as if that was the event I needed, to get me to understand I had to do things differently to change the situation. Back to Marshall Goldsmith,

“There’s nothing wrong with understanding. Understanding the past is perfectly admissible if your issue is accepting the past. But if your issue is changing the future, understanding will not take you there. My experience tells me that the only effective approach is looking people in the eye and saying, “If you want to change, do this.”

Focussing on my own past successes, and how events had conspired against us, was not helping me. In fact, it was holding me back. Which brings me to general practice. Practices are in a difficult position. It is not their fault. But they are the ones in the difficult position. Getting out of this position requires different behaviours to those that were successful in the past.

This is the kind of thing that is easy to say (or blog about!), but hard to act upon. It only becomes possible when an individual really believes things need to change, because without that conviction people take half-hearted steps (or none), or do the same as they have always done, which won’t lead anywhere productive. I don’t know what the equivalent of my ‘authorisation-moment’ will be for individual GP partners, or practice managers, or federation leaders, but the truth of it is that for their situation to change, they are the ones who will need to change. Not to satisfy others, but for themselves.

The environment general practice now finds itself in requires collaboration (with other practices, NHS organisations, the voluntary sector, social care), a willingness to explore new ways of working, and an openness to letting others do what for many years has been the sole domain of GPs. The changes themselves are not that difficult, but personally getting to the point where you are prepared to make them, and adopting the new behaviours that are needed, is.

If we could apply Marshall Goldsmith’s work to general practice directly, perhaps it would read: “What got general practice here won’t get general practice there: How successful practices become even more successful”. Or “What got GP federations here won’t get GP federations there: How successful federations become even more successful”.

The world has changed for general practice, and, like it or not, it is GPs and those working in general practice that will need to change if general practice is to thrive into the future.

6
dec
0
Accountable Care Clinical Commissioning Part 2

Becoming a butterfly…Part Two

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

General Practice and the Transition from Clinical Commissioning to Accountable Care –2

Last time (here) I explored the negative impact that dual running the existing commissioning system and the future accountable care system was having both on general practice, and on the success of the new accountable care models themselves. We want GPs to focus on engaging with accountable care, to ensure general practice and the registered list is central to it. But the commissioning system hasn’t stopped, and we still want GPs leading and actively participating in the commissioning system.

By creating an artificial split between general practice as providers through federations and general practice as commissioners through CCG localities we are making it difficult for core general practice to be involved in the new models (How are practices represented? Do federations have a mandate to speak for practices? etc.), wasting valuable general practice time, and unnecessarily limiting the GP leadership capacity available to the new system.

If the heart of the transition is moving where the energy for redesign sits, how might we shift it from the GPs sitting in their commissioning role, to the GPs sitting in their provider role (rather than simply asking two different groups of GPs to do both)?

Could we transfer the responsibility for redesigning services from CCGs to groups of providers now? In practical terms, could we cope now without GPs carrying out their commissioning role, and ask them to take on the redesign role as providers, working with local partners? Could we transfer the resource we spend on our CCG locality structures to the GP federations (and what is the real return on the investment of that money anyway?), against a set of outcomes and outputs that we want in return? Wouldn’t that, in fact, be modelling the future?

Immediately I can feel the unease growing around the dreaded conflicts of interest. How can we give GPs the responsibility to design something they will potentially benefit from as providers? It has been the bane of CCGs in recent years, and this could feel like a step backwards.

But isn’t is true that within an accountable care model of providers working together within a fixed envelope of money, some of those providers sat round the table will end up providing more, and some will end providing less? The prevailing wisdom suggests the likely shift is from secondary care into primary care (a shift the purchaser/provider system singularly failed to enact). The logic of the new system is that, for the new system to be successful, exactly what we fear from a conflict of interest perspective (general practice designing services that shift resources into primary care) is what is needed for the new system to succeed.

If we place the redesign resource for a system into a provider partnership that the GP practices are part (maybe a major part) of, then all we are doing is modelling the future. We have to unlock the creativity of front line clinicians working together to improve the lives of the populations they serve. We can’t do that if we bind them in bureaucracy.

Attempts to develop a contractual approach to overcome the potential conflicts issue (the dreaded ACO contract) has already proven unwieldy and time consuming, focussing energy on form and governance structures and away from the key challenge of making change. In our transition plans from the old system to the new we need to find a way of shifting the energy for redesign as early as possible to make it central to the new way of working.

We are wasting valuable GP resource in dual running a system we are winding down alongside the new system we are trying to put in place. We need to accelerate the shift from the old to the new. The longer we wait, the harder it will be to engage general practice in the new model, and the more disenchanted they will be with the old model as it is dismantled around them. If we don’t do this now, then when?

29
nov
0
Accountable Care Clinical Commissioning Part 1

Becoming a butterfly…Part One

Posted by Ben GowlandBlogs, The General Practice BlogNo Comments

General Practice and the Transition from Clinical Commissioning to Accountable Care – 1

The NHS is faced with something of a conundrum at present. We have the system of commissioners and providers as laid out in the legislation and statutory architecture, and the system of providers working together as laid out in the Five Year Forward View and STPs. The two are fundamentally different. The conundrum is how to manage the transition from one to another, without any legislation or mandated transition plan.

General practice sits at the very heart of this transition. The new models of care are based on the registered lists of GP practices, yet all the while it remains mandatory for these practices to be part of a CCG. We want GPs to (eventually, at a time yet undetermined) stop doing “commissioning”, and (immediately) to start doing “accountable care”. Unsurprisingly, the early lessons are that general practice needs to be involved in accountable care from the outset.

The transition has of course already started. STP leaders and teams are growing in number and power, and we are starting to see reductions in the number of CCGs and also in the number of CCG Accountable Officers, as CCGs increasingly share management teams. The overall system leaders are no longer exclusively commissioners, and they are grappling with how to make the transition from the existing system to the new one a reality.

At the heart of this transition is the shift of where what I would call the “energy for redesign” comes from. In a commissioner/provider split, the commissioner designs the pathways and ways of working and contracts each provider to deliver their part. Within an accountable care model, the providers work together to redesign the pathways and the interfaces between organisations and clinicians. For me, it is this shift of the energy for redesign from commissioners to providers that is critical to the success of the new system.

If we go back to why we wanted GPs involved in commissioning in the first place, it was because of their unique perspective on the wider healthcare system and how it impacted on their patients, and their ability to use this to drive change for their registered list. Is it any different with accountable care? I don’t think so. We are simply trying to harness the same insights, knowledge and experience within a different system. In truth, we are doing it because the commissioning system has not worked as the driver for the change that the NHS needs.

How, then, do we make this transfer of the energy for redesign from commissioners to providers a reality? How do we empower GPs to start to make the changes we wanted them to make in commissioning, but not through contracts but by building relationships with other providers?

Most places are encouraging the development of federations, or other at-scale general practice vehicles. These are then seen as the GP “providers”, and the sub-structures of commissioning groups, often called localities, are seen as the GP “commissioners”. We then try and talk accountable care and the future with the federations, and commissioning and business-as-usual with the localities. But this has three fundamental problems. First, we are halving the already limited GP capacity available by splitting it between the two. Second, engaging GP federations rather than practices and practice representatives in emerging models of accountable care (unintentionally) limits the general practice input to those activities the federation undertakes and often excludes core general practice. And third, the GPs who have built experience of working in partnership through their CCG work are left in the commissioning camp when they are desperately needed in the accountable care camp.

Dual running general practice as both commissioners and providers suits the system because of the complexity of the current situation, but we are not serving an already overstretched general practice well, and we are diluting the potential impact of the new system right from its very inception. Next time I will explore whether within the transition we can empower general practice to make a fuller shift to the new system earlier, without resorting to the bureaucracy and upheaval of the proposed ACO contract.

 

22
nov
0
Joining A Federation

Seven good (and seven bad) reasons to join a federation

Posted by IanBlogs, The General Practice BlogNo Comments

Joining federations is currently de rigueur in general practice. But is it right for everybody? For federation leaders, is it important that practices join for the right reason, or is it more important that as many practices as possible join? And for a system trying to push for general practice at-scale, does the underlying motivation of practices to work together matter, or should we be pursuing the goal of scale regardless?

As someone who has led a federation in the past, and now works with practices and federations up and down the country, my view is there are good and bad reasons for practices to join a federation. When federations form with practices joining for “good” reasons, federations can fly quickly. Initiatives can get off the ground rapidly, a powerful voice for general practice can be formed, and partners can find the group easy to do business with.

Conversely, when practices have joined a federation for the “bad” reasons, progress can be painfully slow. The group can be beset by internal arguments and in-fighting from the start. Gaining practice agreement for any, even minor, initiative can be extremely challenging and the leaders are often disconnected from their members; unable to speak with any real authority for them.

Here are my seven “good” and “bad” reasons to join a federation:

15
nov