Make or Break for At-Scale General Practice

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.

How COVID-19 is re-shaping general practice

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.

Coronavirus: Disabling or Enabling?

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.

Has the employment liability question been answered?

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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The PCN Clock is Ticking: Your 3 Month Plan

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.

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