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Advice and Guidance: Centralised Micromanagement at its worst

Posted by Blogs, The General Practice BlogNo Comments

A wiser man than me noted that every NHS reorganisation over the last 20 years promised to decentralise power to the front line but actually resulted in more centralisation than existed before.  So, will the newly announced changes to NHS England and ICBs result in the same?

When the government explained its decision to scrap NHS England it said, “The changes will crucially also give more power and autonomy to local leaders and systems – instead of weighing them down in increasing mountains of red tape, they will be given the tools and trust they need to deliver health services for the local communities they serve with more freedom to tailor provision to meet local needs.”

It is a pretty stark promise of more local autonomy, but one that sets off alarm bells in those concerned that yet again this will result in even more centralised control.

The first articulator of this concern was, surprisingly, former Health Secretary of State Patricia Hewitt, who also announced that she was stepping down from her current role as ICB Chair for health reasons.  She said, in an interview with the HSJ, “The real problem is combining the abolition of NHSE with hugely increased micromanagement from the centre”, concluding “it’s one more tightening of the screw, I fear”.

In response a DHSC spokesperson said, “We aren’t going to replace micromanagement from NHSE with micromanagement from DHSC”, which is a pretty firm rebuttal, but not enough to reassure sceptics (like me).  Instead, these words need to translate into action.

It is into this context that the Advice and Guidance Operational Delivery Framework for ICBs has just been published.  This is of material interest to general practice, who at the same time have received their own Enhanced Service specification for advice and guidance.

Unsurprisingly, the framework does not give any of the promised freedom for local areas.  Instead, it provides a list of more than 20 indicators and over 70 minimum standards that ICBs need to achieve. These are not outcomes, but rather a huge list of process actions that are very specific, such as “complete clinically led audits quarterly at specialty level” and “agree and develop a peer learning programme to address identified learning needs”.

Not only is it disempowering, but it is hugely time consuming.  ICBs are “required to review the key indicator and related minimum standards and assess the level of implementation within their system for the quarter being completed”.  Just think of the work involved in trying to complete the template against the 70+ minimum standards every quarter.  All effort shifts from making advice and guidance actually work locally to complying with the demands of the centre and reporting upwards.

The document also contains what it terms “guiding principles of accountability”.  These state that general practice has responsibility to “reduce unwarranted variation in the use of Advice and Guidance”, and that GP Partners are accountable for this(!).  However, a quick cross check to the DES and there is no mention of “unwarranted variation”.  Indeed, there the focus is solely on when advice and guidance is actually being used, with zero on an expectation of overall usage.

As a result, many practices will end up being questioned about their rate of usage of advice and guidance, which is not included in any contract they have signed up to.  I doubt it would take much of this type of inappropriate pushing for many practices to turn their back on the DES altogether.

It could, of course, be totally different.  If the national teams had resisted the urge to micromanage, then local teams could have brought primary and secondary care clinicians together to have productive conversations that could move the whole process away from box ticking into one with an education focus to improve the service for local patients.  But, sadly, we are where we are.

This is material for general practice.  While practices can ultimately ignore their ICB and focus on delivering the contract they have signed up to, there is wider talk (including from new NHS CEO Jim Mackey) about integrating general practice into the NHS via local care organisations and the like.  Should this happen, while the current system remains, there would be no escaping the top down NHS pressure, and practices would undoubtedly face constant questions not just about their usage of advice and guidance but also about their access times, e-consultation rates, rate of A&E attendances etc etc.

The message for general practice must surely be that unless there is a demonstrable commitment to devolve decision-making (particularly about how to do things like advice and guidance) to local providers then the independent contractor status, and the protection it affords from this NHS madness, must remain sacrosanct.

26
mar
0

What do the Changes to NHS England and ICBs mean for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

In a tumultuous couple of weeks for the NHS the government announced that NHS England is to be abolished, and that Integrated Care Boards (ICBs) are to reduce costs by 50% by October.  What will these changes mean for general practice?

The BMA does not come out either in favour or against the abolition of NHS England, seeing the potential of the removal of a layer of bureaucracy but expressing concern about the disruption such a change will bring.

The staff affected have already not been well treated by the way the communication has been handled, and the political point scoring around reducing bureaucrats has exacerbated this.  It is inevitable that the changes are going to cause a huge amount of disruption, and I very much feel for those caught up in the middle of all this.

My sense, however, is that the biggest impact on general practice will not be just the turmoil of the coming months.  In the medium to longer term these changes could impact the freedom of local areas, fundamentally change local contracting arrangements and potentially have significant implications for the future of the independent contractor model.

  1. The Freedom of Local Areas

The Department of Health insists the changes will lead to more devolution of powers and responsibilities to local areas.  However, concerns have been raised in certain quarters (in particular outgoing ICB Chair and former Secretary of State Patricia Hewitt) that overbearing performance management by ICBs and NHS England regional teams will simply be replaced by (worse) micromanagement direct from the centre.

What remains to be seen is whether as part of these changes the government is prepared to relinquish the notion of “grip” that came to the fore 20 years ago and support local innovation and autonomy, or whether it will simply seek to centralise the mechanism for exercising control.

The status of general practice as independent contractors has largely protected it from the control the NHS machinery inflicts on front line providers and local area teams.  Those GPs who have engaged with CCGs and ICBs will have experienced it, and it is something that has undoubtedly contributed negatively to both NHS performance and staff experience in recent times.

However, it is likely to become much more relevant to general practice because this freedom (or control) will apply to the new neighbourhoods that emerge from the forthcoming 10 year plan, to which the future of general practice seems inextricably linked.  Even in his letter to the GPC confirming the government’s commitment to securing a new substantive GP contract Secretary of State Wes Streeting said he was committed to, “deliver meaningful reform to establish a modern general practice at the heart of a neighbourhood health service”.

The desire for central control has stifled local innovation and freedom to act, and diverted huge amounts of time, resources and energy away from driving local change.  The changes could be positive and mean neighbourhoods have a freedom to shape services to meet local needs that has been absent in recent times, or it may have the opposite impact. We will have to wait and see to find out.

  1. Local Contracting Arrangements

The biggest direct role of NHS England and ICBs concerning general practice has been contract management and support via the local primary care teams.   After their dismantling in 2013 when responsibility was shifted from PCTs to NHS England, and then shifted to first CGGs and subsequently ICBs, it is not a surprise these have not been in great shape in recent years (although some have done remarkably well despite all of this).

There has been more of a focus by the centre on the contract itself in recent years, e.g. when primary legislation was passed in May 2023 changing the contract to require practices to respond to patient requests on the day the request is received.  In this year’s planning guidance NHS England promised a new “Commissioning and Transformation Support Programme” to support ICBs to “create the right conditions for improving general practice, including contractual management and transformation”.  This was backed up by Secretary of State condemning “unwarranted variation” in GP performance and exhorting ICBs to target practices who are “coasting”.

So, the question is whether these latest cuts mean all of this will fall by the wayside, or will we see a more distant, impersonal and potentially harsher contract management approach being taken towards general practice?

Meanwhile it is neighbourhoods that have been tasked with improving access to general practice.  What we need to look out for is whether it will be neighbourhoods as they emerge who take on the role of local general practice contract support, or whether we will see a shift to a more formal style of GP contract management from larger more remote ICB teams.

The demise of NHS England and shrinkage of ICBs may even lead to local providers taking on the GP contracting role.  The HSJ has suggested that the changes will inevitably lead to the rise of “local care organisations”, with a lead provider responsible for neighbourhood services.  The predominance of acute trust CEOs on the NHS England transition executive, along with the model already operating in new NHS CEO Jim Mackey’s home patch of Northumbria, may signal a shift to these being led in many places by the local acute trust.

  1. The Independent Contractor Model

The lack of anyone to manage the GP contract even raises the question of what the consequences could be for the independent contractor model.  In what is unlikely to be coincidental timing, the Nuffield Trust have just published a report questioning the longer term viability of the partnership model, and called for alternatives to be urgently explored.  The Secretary of State has seemed more positive in recent weeks about the model, but has in the past suggested a wider range of options also need to be considered.

Even if the core national contract remains into the longer term, it does seem there is the very real possibility that local enhanced service contracts will be picked up and managed by lead local providers overseeing the new neighbourhoods.  This in turn could well accelerate the development of other models for general practice, as local areas seek to replicate the type of model in existence in Northumbria.

12
mar
0

5 Things we can learn from the New GP Contract

Posted by Blogs, The General Practice BlogNo Comments

I am sure you have had chance to see the changes to the GP contract for next year by now, the headline of which is an increased investment into general practice for the first time in what feels like a very long time.  But what can we learn from the new contract?  Here are 5 initial observations.

  1. This government wants to invest in general practice

Last year when the Labour government came into power they increased the global sum by 7.4% to fund GP and practice staff pay rises worth 6%, and this has been followed up with a 7.2% cash growth on the total contract funding envelope in this year’s settlement.

This is in stark contrast to the previous administration, who steadfastly refused to release any additional funds beyond those agreed in the 2019 contract, despite inflation running into double figures.  Not only that, but overall money is extremely tight, both in the NHS and more widely across government, and so this injection of funding is not in line with what is happening in most other areas.

The government has pledged to shift care from hospitals to the community, and to increase the percentage share of NHS funding that primary care receives, and this settlement indicates that they are looking to make good on these promises.  This is good news for general practice, and holds promise for the future.

  1. Life is not going to improve quickly for practices

The less good news is that all of the new investment is likely to get swallowed up by either new or existing cost pressures.  Of the global sum increase of £743M, it is estimated that £300M will be swallowed up by the new employer national insurance contributions and increase in the national living wage, and a further £300M to fund a 2.8% pay uplift for staff.  This only leaves £143M to fund any other new cost pressures, and to try and start to make a dent in the backlog of unfunded cost pressures from previous years.

So while at least things will not get worse financially for practices this year (which in itself is a change from previous years), they also are unlikely to get much better.

  1. Access is the priority for general practice

For all the talk about neighbourhoods in recent times, these changes reinforce the priority that the government gives to improving GP access.  The key inclusion into the contract is the requirement for practices to keep their online consultation tools on for the duration of core hours from the 1st October.

The delayed implementation date and the multiple references to “necessary safeguards” indicate this was a tough part of the contract changes to agree, but one that NHS England was not prepared to back down on.  Given improvements to GP access is also a key priority for the emerging neighbourhoods for this year we should not expect the pressure in this area to ease any time soon.

  1. PCNs are not going anywhere

For the GPC’s part, they have clearly worked hard to negotiate more flexibility to the ARRS pot.  A number of concessions have been made such as the caps on numbers of staff being removed, the pot for new GPs no longer being separate, the maximum reimbursable salary for GPs being increased, and the addition of practice nurses to the roles that can be employed.

However, what the GPC really wanted was for the £1.6bn of ARRS funding to be shifted into the core contract.  This was not agreed by NHS England.  There is to be a “joint review on the future of ARRS” through 25/26, but that really just points to an inability to get to an agreement within these contact discussions.

The reality is that while it would have been cost neutral for NHS England to meet this demand, they know that the majority of PCN funding is within the ARRS pot, and that dismantling it would most likely effectively precipitate the demise of PCNs.  PCNs clearly form an important component of the neighbourhoods that we will find more out about in the 10 year plan, and having fought so hard and invested so much in their establishment over the last 6 years NHS England is not prepared to simply let them go.

  1. Much bigger change for general practice is on the way

This contract very much has the feel of a holding contract, one that is designed to keep things going, remove the cloud of collective action and suggest positive intent without introducing any major changes.

However, GPC England has been clear that acceptance of this contract is conditional on a commitment from the government to a “full renegotiation of the new national contract, beginning within this parliament”.  The government, meanwhile, is closing in on the publication of its much-touted 10 year plan, and for the shifts it is seeking to achieve changes in general practice are going to be required.

This all points to much bigger changes ahead.  At least now the two sides are talking and have been able to come to an agreement for this year, but any trust that has been built is likely to be needed in the even trickier negotiations that await in the years to come.

26
feb
0

Neighbourhoods: 6 Things to Look Out For

Posted by Blogs, The General Practice BlogNo Comments

While we know the impact of neighbourhoods could potentially be hugely significant for general practice and PCNs, the recently published neighbourhood health guidelines told us very little about them.  This is because the powers that be want them to be locally developed rather than nationally imposed.

But this in itself is important.  It means all of the most important decisions about neighbourhoods are going to be taken locally.  Neighbourhoods in one area could look very different to neighbourhoods in another.  The devil will be in the details.

It almost goes without saying, then, that general practice needs to make sure it is directly involved in the decision making about the local development of neighbourhoods.  According to the guidelines there needs to be, “a mechanism for joint senior leadership, such as a joint neighbourhood health taskforce, in each place to drive integrated working, comprising senior leaders from the constituent organisations across health and care, including the acute hospital”.  General practice needs to make sure it is on whatever this looks like in their local area.

But getting on this group or taskforce is only step one.  Once there, what do general practice leaders need to be seeking to influence?  Here is an initial list of 6 things to look out for:

  1. The Configuration of PCNs. The Neighbourhood Health guidelines avoid the question of what the configuration of neighbourhoods should be, instead leaving this for local areas to decide.  While some areas may end up with a configuration that matches the current PCN configuration, many areas will not.  A key question will be how, then, any misalignment between the two should be handled, and whether attempts will be made to alter the configuration of PCNs as a result.

 

  1. Control of PCN Resources. While we may see an investment in the neighbourhood infrastructure via the forthcoming 10 year plan, as it stands the current guidelines do not suggest that there will be any.  Given the lack of additional resources there is a real risk that the system will try to treat PCN resources, and in particular the ARRS staff, as neighbourhood resources rather than resources that belong to general practice.

 

  1. Improving GP Access. It seems somewhat incongruous that neighbourhoods, that are supposedly about joint working between organisations, are to have a focus on improving the performance of one of these organisations (general practice) as an initial priority (“NHS England regional teams… should work with systems to agree locally what specific impacts they will seek to achieve during 2025/26. We expect these to include, as a minimum, improving timely access to general practice”).

One question this raises is how neighbourhoods will seek to achieve this.  The risk to watch out for is that systems via neighbourhoods may choose to adopt a top-down, performance management approach, rather than one that seeks to reduce pressure on practices by maximising the contribution of other local agencies.

  1. The Role of PCN CDs. If PCNs are to form one component of neighbourhoods alongside a range of other local providers, an important question will be where PCN CDs end up sitting within the neighbourhood leadership infrastructure (if anywhere).  Will PCN CDs be able to play an influential role in shaping and leading neighbourhoods, or will the local system attempt to sideline them in favour of giving power to others?

 

  1. The “Integrator” Function. All the indications are that an at-scale organisation will be sought to take on what has so far been termed an “integrator” function (for example in North West London – here).  This is where one organisation takes on responsibility for bringing all the providers in the neighbourhood together, which in turn could bestow considerable control of the neighbourhoods to that organisation.  While theoretically this could be a primary care organisation, a community health provider or a local authority, what is important is which of these it ends up being locally.

 

  1. Funding Streams (and link to GP funding streams). If neighbourhoods are to have any kind of authority then they will need to have clear funding streams.  The guidelines, however, do not make clear what these will be.  The concern might be that some systems may choose to set neighbourhoods up as commissioning style organisations, that hold all of the local funding for the local providers, but with the freedom to move it around to “best meet local needs”.  This could potentially put GP and PCN funding at risk.

The other funding stream risk GP leaders will need to be aware of is where finances are predicated on a series of “invest to save” business cases, designed to shift resources from secondary care to the new neighbourhoods.  These have a terrible record of success, largely due to fixed capacity in secondary care and the ongoing increase in overall demand (Joe McManners explained this well on our podcast last year), and so such a design would most likely be setting neighbourhoods up to fail.

These are just some of the initial things for GP leaders to be looking out for.  The most important thing at this stage is to ensure that general practice is represented on the local neighbourhood development group, and that there is effective two way communication between this representation and practices and PCNs.

12
feb
0

What is in Store for General Practice Next Year: Change is Coming

Posted by Blogs, The General Practice BlogNo Comments

A whole new raft of documents was published by the government and NHS England at the end of January, and they have significant potential implications for general practice.  What can we learn from this latest batch?

These new publications include the latest “mandate” from the government for NHS England, which outlines the government’s expectations for next year, the Planning Guidance for 25/26 from NHS England to the service, NHS England’s new operating model, and the new Neighbourhood Health Guidelines which outline how neighbourhoods are to develop next year.

There is a consistent theme throughout these documents which will come as no surprise: improving GP access.  The planning guidance lays down the target for systems to improve patients’ access to general practice, including patient experience.  While it does not set out a numerical target it does state that GP access will now be measured by a regular Office for National Statistics survey.

Of the 5 government Mandate objectives for the NHS, one is to “reform to improve primary care access”.  What does this “reform” entail?  In part it is the “tackling unwarranted variation” mantra that never gets anybody anywhere.  Wes Streeting said in an interview with the HSJ that he wants ICBs to target practices “who are coasting at the expense of those who are striving hard”.  According to Wes there are “some practices who are not working as hard as they could and driving improvements as they could for their patients”.

Let’s put aside (if we can) the fallacy of diagnosing variation in access performance as a pure function of individual practice effort, and how offensive this is to all of those practices doing their best with inadequate funding for the vastly different practice populations they serve.  What is more worrying is that NHS England appear to have taken this to heart.

In their new Operating Model NHS England promises that “in the Spring we will provide you with details of a new Commissioning and Transformation Support Programme for GP commissioners that will support ICBs to create the right conditions for improving general practice, including contractual management and transformation leading to benefits for patients and the workforce”.  This has the heavy whiff of using blunt contractual and performance management to tackle variation (based on the diagnosis that the issue is lack of effort).  It is noteworthy that practices themselves are not listed as one of the supposed beneficiaries of this new approach.

In turn in the new Planning Guidance all ICBs are to, “put in place action plans by June 25 to improve contract oversight, commissioning and transformation for general practice, and tackle unwanted variation”, i.e. outline how they will put this new guidance into practice locally.

The other main element of the government’s mandate for the NHS to reform to improve primary care access is that it should, “develop approaches with relevant partners to improve financial flows within health and social care to provide more coordinated services to patients as a step towards building a new neighbourhood health service”.  What does this mean?

Well this is not as clear, because the mandate does not elaborate any further.  The new guidelines on neighbourhoods lack specificity.  They do not say what a neighbourhood is, what size it should be, what population it should cover, or how it should align with existing ICB or PCN structures.  While the official line is that this is to leave freedom for local teams to develop the model that will work best locally, it would be a huge surprise if the 10 year plan once it arrives does not fill in at least some of these blanks.

The neighbourhood guidelines do, however, make a couple of relevant things clear for general practice.  The aim of neighbourhoods (at least in the short term) is to both reduce the pressure on acute hospitals and to help with the immediate financial challenges systems are facing.  This means no new investment has (so far) been identified for them, and (one can’t help feeling) that they are therefore being set up to fail (Joe McManners eloquently explains in this episode of the podcast why neighbourhoods need to be seen as a long term investment in reducing growth in activity rather than a mechanism for reducing activity in the short term).

The relationship between neighbourhoods and general practice is also noteworthy.  General practice is not portrayed as a co-creator of neighbourhoods but rather as a recipient of them.  One of the initial six “core components” of neighbourhoods is “modern general practice”, as something for neighbourhoods to implement.  General practice appears more as a target of neighbourhood activity than as something they will be an integral part of.

This is further reinforced by the fact that it is ICBs and local authorities that are asked to jointly plan a neighbourhood health and care model for their local population.  There is a requirement for, “a mechanism for joint senior leadership such as a joint neighbourhood health taskforce in each place”.

It could even be that neighbourhoods end up being tasked with the role of tackling unwarranted variation in access between practices.  They could potentially then end up being the performance managers of practices and take on a much more directive relationship than we have been expecting.  There is a hint of this in the mandate which states, “improving primary care is essential to support a move to a neighbourhood service”.

PCNs, meanwhile, are conspicuous by their absence.  At this point it seems highly unlikely PCNs will evolve into neighbourhoods, but rather that they will exist within them (and be subservient to them).  Where PCN and neighbourhood boundaries do not align I don’t think it will even be a question when it comes to which one will have to change.

All this points to “reform” of general practice being high on the agenda.  We don’t yet know what the reference to improving financial flows for general practice means from the Mandate.  We don’t yet know what the relationship between practices, PCNs and neighbourhoods will be.  There is, however, quite significant room in what has been said in these documents for big changes to be proposed, but we will only get more clarity on these once next year’s contract and the 10 year plan have been published.

If there is one actionable take away for general practice from these documents, it is this: make sure you are as involved as you can be in the development of neighbourhoods locally.  Make sure that general practice is on the “joint neighbourhood health taskforce” or whatever it is called locally.  Freedom exists for local areas to determine the final nature of neighbourhoods, so it is crucial that general practice is around the table shaping how this should be.  This will be the best (and maybe only) way of mitigating the potential negative impacts of whatever the final guidance ends up being, and once local plans are made it will most likely be too late to do anything about them.

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