PCN vs Practice Independence

PCNs are not popular in some quarters of general practice primarily because they are seen as a threat to the independence of the individual practice.  But is there a bigger threat to practice independence than PCNs, and could it even be that PCNs may become key to maintaining practice independence?

Funding and resources are increasingly coming to practices via the PCN route (as opposed to directly via the contract).  Inevitably alongside any additional funding and resources are increased delivery requirements.  It is the lack of direct control of the resources alongside the additional work which is behind much of this growing practice resentment of PCNs.

But more changes are coming.

Since October PCNs have taken over responsibility for enhanced access.  We are seeing a mixed picture of delivery across the country.  Some PCNs have taken over this delivery from the local provider, others have simply come to their own arrangements with the local provider and yet others have created all sorts of hybrids in between with mixed models of delivery and even whole new providers in place.

Now, we know from the Operating Framework that a “General Practice Access Recovery Plan” is on its way.  While we don’t know what will be in it, there are some elements we can predict.  Most likely is the number one action outlined in the implementation plan from the Fuller Report, which was to:

Develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for practices.  This should be for all patients clinically assessed as requiring urgent care, where continuity from the same team is not a priority” p34.

Specifically, the report says that it is for, “primary care in every neighbourhood to create single urgent care teams and to offer their patients the care appropriate to them” (p11).

Very quickly, it appears, we may be in a place where PCNs are expected not just to offer extended hours across all of its member practices, but also a system for delivering all urgent appointments across core practice hours.

Let’s leave aside the mechanics of how the centre might expect to impose a system that takes away activity that is core contract activity (and, one assumes, also the funding that goes with it), and for arguments sake assume that this is what happens.  In this situation does a PCN really want to be outsourcing the delivery of these appointments to a third party provider?

It is one thing for a third party to be providing additional appointments on top of those that a practice has traditionally been expected to provide.  But it is another for such a provider to take on responsibility for delivering in hours appointments that have always been part of the core contract.

Even putting aside the impact this would have on the practices’ ability to deliver effective continuity of care, the threat to practice independence at this point surely becomes much more real.  If a practice is not responsible for one aspect of its population’s core primary care, what is to stop other responsibilities being taken off it?  Where does that road end up?

Meanwhile, the PCN remains a contractual entity owned entirely by it practices.  While individual practices may not be able to retain control of this agenda, groups of practices working together as a PCN can.  If the group can work together they can find a way through this that protects their collective independence.

So while there is a loss of control at an individual practice level in operating across the PCN, the group of practices can retain collective control by working together.  What the PCN provides is additional running costs, staff and resources to enable this joint working to be effective.   Now may well be the time for practices working together as PCNs to start considering how they can ramp up their in-house delivery abilities and reduce any reliance on external providers, as a means of protecting their collective independence.

The End of Independent General Practice?

The Labour party has launched an offensive against general practice in recent days.  First the Shadow Health Minister Wes Streeting says he wants to “tear up” the “murky, opaque” GP contract, and now Labour leader Keir Starmer has doubled down on the comments and said he wants to take away the GP contract and make GPs direct employees of the NHS.

Now we are in the odd position of the Conservative party defending the GP partnership model.  In Prime Minister’s Questions on 11th January Rishi Sunak said, “‘I’ll tell you what the NHS doesn’t need. What they don’t need is Labour’s idea – Labour’s only idea – which is for another completely disruptive, top-down, unfunded reorganisation buying out every single GP contract”.

Maybe Labour’s position is not surprising.  They wanted to nationalise general practice back in 1948, and only reluctantly agreed to the current situation in order that they could push ahead with introducing the NHS.  Since then GPs have maintained such huge popularity ratings with the general public that it has been impossible for them to challenge the independent contractor model, and to press ahead with any plans to nationalise general practice and bring it in line with the rest of the health service.

But now things have changed.  The popularity of GPs has fallen sharply as access challenges have risen and the media campaign demanding immediate access to an in-person appointment with a GP has continued largely unchecked.

Labour has pounced on this opportunity and is now portraying GPs as money-grabbing private contractors, who undertook the vaccination programme for no other reason than personal financial gain, in an attack that they would have not even considered only a few years ago.

Of course, this flies in the face of any reasonable analysis of what is going on.  The recent Health and Social Care Committee Inquiry Report into general practice (an all party document!) reported that, “Historically one of the key drivers of innovation and improvement in general practice has been the GP partnership model, which gives GPs the flexibility to innovate with a focus on the needs of their local population. We know there are significant pressures on GP partners at the moment but the evidence we received was clear that the partnership remains an efficient and effective model for general practice if properly funded and supported… Rather than hinting it may scrap the partnership model, the Government should strengthen it” (p4).

There is a belief amongst some that others (“professional NHS managers”) would be able to manage general practice better than GP partners.  But only last week a hospital in Swindon returned the contracts of two GP practices so that they could have “more opportunities to draw upon shared learning and best practice” from nearby practices.  It turns out running practices needs its own expertise, and this is not one that currently exists in other NHS organisations.

The idea that introducing the very NHS bureaucracy to the service that the government has consistently said it is trying to cut from the health service would be somehow a solution to the challenges facing general practice can only be described as political, and never as either pragmatic or realistic.

But ultimately the NHS is political.  General practice at a national level is not functioning as an effective political operator.  So while the logic of Labour’s political position is not intellectually defensible, unless general practice gets its act together nationally it may well be that the GP partnership model will end up as a political casualty, should Labour maintain its current lead in the opinion polls and win the next election which will take place within the next two years.

What the 2023/24 Operating Guidance Means for General Practice

Every year the powers that be produce “operating guidance” for the NHS for the forthcoming year. It is published at around Christmas time (happy Christmas…) so that NHS organisations and Integrated Care System (ICS) partners can build the guidance into their plans for the forthcoming year.  True to form, this year the guidance was published on 23rd December.  What implications does it have for general practice?

General practice features right from the outset.  The immediate priority for the NHS is to “recover our core services and productivity” and along with ambulance, A&E and elective waits the document prioritises “make it easier for people to access primary care services, particularly general practice” (p3).  No surprise that it is GP access that takes centre stage.

There are three specific general practice targets (p7):

  • Make it easier for people to contact a GP practice, including by supporting general practice to ensure that everyone who needs an appointment with their GP practice gets one within two weeks and those who contact their practice urgently are assessed the same or next day according to clinical need
  • Continue on the trajectory to deliver 50 million more appointments in general practice by the end of March 2024
  • Continue to recruit 26,000 Additional Roles Reimbursement Scheme (ARRS) roles by the end of March 2024

The guidance further notes that an ominously titled “general practice access recovery plan” is being produced and will need to be implemented when published.  It certainly feels like this document will contain more of the actual detail of what systems are expected to impose on practices next year.

There is an annex that, “sets out the key evidence based actions that will help deliver the objectives set out above and the resources being made available to support this” (p8).  I looked forward to turning the page and finding out what these were, but was somewhat deflated to discover that for general practice these are to, “ensure people can more easily contact their GP practice (by phone, NHS App, NHS111 or online)” and “transfer lower acuity care away from both general practice and NHS 111 by increasing pharmacy participation in the Community Pharmacist Consultation Service”.

Disappointing, but not surprising.  Things don’t improve when it comes to the money.  Essentially there is no new money.  Instead, there is an overall 2.2% efficiency target.  Systems are expected to pay acute providers payment for activity performed (no block contracts), and every ICS has to come up with a balanced plan.  For general practice we are told funding has already been agreed in the existing 5 year deal (so don’t expect any more), and if local systems have to stick with payment by results there is very little possibility of any new local investment into primary care.

The challenge when it comes to general practice is that the Operating Framework is always published before the GP contract has been finalised.  In the only nod to Fuller (the Health and Social Care Committee Inquiry report is ignored completely) the document states, “Once the 2023/24 contract negotiations have concluded, we will also publish the themes we are looking to engage with the profession on that could take a significant step towards making general practice more attractive and sustainable and able to deliver the vision outlined in the Fuller Stocktake, including continuity of care for those who need it. The output from this engagement will then inform the negotiations for the 2024/25 contract.” (p10).

This leaves us basically where we thought we were, i.e. that the NHS has no intention of doing anything other than imposing year 5 of the 2019 deal for 23/24, and anything new will have to wait for the next contract that will start in 2024.

All of this is hugely depressing given the challenges the service is experiencing.  Any hopes that the Health and Social Care Select Committee Report would mark a shift of emphasis from access towards continuity have been firmly dashed.  Even the mention of continuity of care feels like it has been done as a concession to the profession, as a subtext to the “real” NHS agenda of GP access.

We will wait and see what (if anything) comes out of the contract negotiations, and what horrors await in the ‘access recovery plan’, but all signs are already pointing to a very difficult 2023 for general practice.

PCN Plus Live Event!

Despite how difficult and challenging it is to lead a PCN there are very events that are directly and uniquely for PCN Clinical Directors and leaders, but I am delighted to say that we are putting on just such an event in the New Year – and you can attend for free!

Let me take a step back to explain the context for this event.  A year ago I got together with three amazing colleagues: Dr Hussain Gandhi, PCN CD and co-presenter of the eGPlearning podblast and all round advocate for general practice and in particular technology in general practice; Dr Andy Foster, former PCN CD and also co-presenter of the eGPlearning podblast; and Tara Humphrey, PCN management expert and presenter of the Business of Healthcare podcast.

Our combined experience of both directly leading and supporting PCNs led us to the realisation that there is very little available for those leading PCNs by means of learning and guidance, and that we were best placed to put that right.  We came up with a brand new course specifically designed for PCN leaders, and PCN Plus was born.

We launched the PCN Plus programme back in April this year with just under 30 PCN leaders.  The group have met every month since then, and we have covered a whole range of topics including how to establish a vision for what you want your PCN to achieve, how to engage your practices effectively and deal with any conflict that comes up, how to make the most of the ARRS roles, and how to manage your PCN operations and finances effectively.

It has been great working with such a dedicated group of PCN leaders who have been so keen to find out more about how they can be more effective in their leadership role, and not only learn from us as a group of facilitators but also learn from each other and share their own experiences to the benefit of everyone else.

But as we reach the end of the course there was one thing we all felt was missing – actually meeting up in person!  It is fantastic being able to meet online and there is a great convenience to it, but there is something special about meeting up in person, even more special now we do it so infrequently.  So we agreed that we will hold an event where everyone who attended the course can come in person, and all finally meet with each other and with the four of us who run the course.

The great news is that if you are leading a PCN you too can attend this event!  As well as learning from the experiences of those who have been on the course so far, we will be focussing specifically on the future of PCNs, on what PCNs can do to be effective within the new Integrated Care System, on what is next for PCN CDs and how can PCN leaders prepare for the challenges ahead.

The event is totally free, but places are extremely limited (there are only 40 available in total) and will be allocated on a first come first served basis.  The event will take place on Wednesday 1st March in Nottingham and runs from 1pm to 4.45pm with lunch (also free!) available from 12.30.  You can reserve your place here – I look forward to seeing you there!

The PCN Manager

PCN managers can be annoying.  As if the practice does not already have enough to do, without the PCN manager constantly ringing up or emailing and asking where the practice is up to with this or making sure the practice does the other by the end of the day.  So where does the real value of a PCN manager lie?

Of course the question is really whether it is the PCN itself that is annoying rather than the PCN manager per se.  Is it really the PCN manager’s fault that the IIF has 1,153(!) points available?  Someone has to monitor it.  And if the PCN agrees to a project or way of working, someone has to be in contact with the practices to make sure that everything that is needed is getting done.

It does, however, beg the question of what we really want from our PCN managers.  Is the job of the PCN manager to be the administrator constantly badgering practices to make sure they are doing what they said they would do?  Or if a practice says it is going to do something is it their own responsibility to make sure it is done, and should the focus of the PCN manager lie elsewhere?

The scale and opportunity of PCNs means that they are now at the point where the PCN manager needs to be something more than glorified admin.  They need to be the ones providing strategic leadership support to the Clinical Director and the PCN.

What does that actually mean?  It means that the role of the manager should be supporting the PCN to ensure that it has a clear vision, and that it has a plan in place to deliver that vision.  It means building relationships within and outside of the PCN to enable that plan to be delivered.  It means finding and securing new opportunities for funding and support to help move the PCN forward.

In too many PCNs all of this responsibility falls on the PCN Clinical Director, who has a myriad of PCN things to attend to in very few sessions each week.  Strategy, strategic planning, relationship building and external opportunities are often the first things to go when there are operational and staff issues that need sorting.

The PCN manager is the key.  They are the ones with the capacity to keep the focus on the important as well as ensuring the urgent is dealt with.  The ability of the PCN to establish and maintain its strategic direction is in a large part down to the PCN manager.  The Clinical Director needs their PCN manager to be working with them to keep the PCN on track.

The problem is that many places do not recognise that this is what is needed of the PCN manager.  Instead they actively seek someone to monitor the IIF targets and PCN DES delivery.  They look for someone junior who can “do the doing”, and do not value the strategic and relationship building skills that are actually the ones that have become the most important.

Equally, many PCNs are not prepared to pay for these skills. The reality is that a manager with these skills will be more senior and have more experience.  They may even earn more than the practice managers (which can be a problem in itself).

PCNs are at a critical point.  The resources and opportunity of PCNs have become really significant, but so have the operational and delivery requirements.  One of the keys to making sure that PCNs add value rather than becoming a drain on resources is finding the right PCN manager with the right skills to ensure the full potential of the PCN is realised.

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