A Reminder of the Value of Independent Contractor Status

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

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

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

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

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

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

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

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

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

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

What do ICSs and PCNs mean for GP Practices?

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

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

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

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

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

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

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

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

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

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

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

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

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

A 3 point ICS Strategy for Local General Practice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Why Extended Access is so Controversial

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

What exactly then is the problem?

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

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

The issues can be broadly broken down as follows:

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

 

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

 

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

 

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

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

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

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

Making General Practice Effective within an ICS

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

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

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

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

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

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

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

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

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

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

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

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

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