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.

Dos and Don’ts for the Next Phase of PCNs

The recent PCN guidance signalled a new phase for Primary Care Networks.  In a recent blog I examined the guidance in some details.  The upshot, though, is that delivery expectations on PCNs will increase significantly from the start of October, and then again from March next year.

Covid has directly impacted on PCNs over the last 18 months.  Amongst other it postponed some of the delivery expectations to allow practices to deal with the pandemic and to roll out the vaccination programme.  Meanwhile the ARRS investment has continued.  Now the transition from set up to delivery is happening very quickly, instead of the more gradual shift originally intended.

This is significant for PCNs.  It means a move away from considering how to best use the ARRS funds to requiring a much stronger focus on delivery against the DES specifications, the IIF indicators, and any local schemes that may be in place.

So the set up phase of PCNs is effectively coming to a rather abrupt end, and we are entering a new delivery phase.  How should PCNs respond to this change?  Here are my top 3 ‘Dos and Don’ts’ for PCNs in making this transition.

DO

  1. Do be explicit about the link between PCN and Practice Work

Since 2019 the uplift in funding to the GP contract has come almost exclusively through PCNs.  This trend will continue for the next three years until 2024, and is highly likely to continue beyond that.  The funding and resources that will come to practices via PCNs will soon make up a key part of a practice’s income.  Participating in PCN delivery is not separate (and additional) to a practice’s core work; it is part of it.  For practices in a PCN to make the most of the PCN opportunity they need to work together, and make sure a commitment is in place from each practice to meet the delivery requirements.

  1. Do firm up the agreement between practices in relation to delivery

It is crunch time.  Some PCN targets can only be achieved if each practice plays its part.  But what happens if one practice does not meet the delivery requirements?  What if that means the whole PCN loses out financially? What are the consequences?  How will the PCN respond?  Will the practice have to recompense the other practices for any income lost? How will it work? It is really important practices within a PCN have a clear upfront agreement in place of exactly what the requirements in relation to delivery are, and what will happen if these are not met.  Without these in place life could become extremely difficult over the next few months.

  1. Do put management support in place

Many PCNs have some management support in place, but some still do not.  The latest guidance promises £43M for ‘PCN leadership and support’ this year.  If it is not already, ensuring delivery against all of the new requirements will be impossible for PCN CDs to do on their own from October, so use this funding to put some management support in place.

DON’T

  1. Don’t Change PCNs

Being in a PCN can cause relationships to fray, and working together can sometimes feel more difficult rather than easier over time.  But if you have got this far with your PCN configuration don’t be tempted to change it now.  Changing PCNs means doing all the start up work all over again, and frankly there is not the time to do this as well as meet all the delivery requirements.

  1. Don’t ignore the fact that a practice is not delivering

Conflict is difficult, and PCNs have been working hard to build relationships between its practices over the last two years.  But if a practice is not meeting its extended hours commitments or its care home requirements, and that is impacting the PCN as a whole, then it needs to be tackled.  Ignoring non-delivery now sends a message that non-delivery is ok to everyone, which in turn will make effective delivery across the increasing range of requirements almost impossible to achieve.

  1. Don’t waste your time in pointless meetings

The value of PCNs will ultimately come from their ability to make a difference to their local population.  It will not be determined by the number of system meetings that the PCN attends.  This phase for PCNs requires an internal focus to make sure they are each able to deliver effectively.  A PCN’s influence will increase if it can gain a reputation as one that can make change happen, versus one that attends a lot of meetings with little end product.

What Next for General Practice Nursing?

General Practice nursing has reached something of a hiatus: the ten point action plan published in 2017 has expired and as it stands there appears to be nothing new taking its place.  At the same time the Primary Care Networks (PCNs) dominating much of the general practice agenda make relatively little mention of the nursing workforce.  So where does this all leave general practice nursing?

At the time of the publication of the General Practice Forward View in 2016, along with the subsequent 10 point action plan for general practice nursing, there was a gentle optimism that the problems within the general practice nursing profession were finally being recognised, and action was being taken to resolve these.  But fast forward to five years later and it seems the situation remains critical.

While the numbers of nurses attracted into general practice has risen over the last few years (NHS Digital data reports just over 24,000 nurses in 2020 compared to c15,000 in 2015), the fundamental problems in relation to retention of these nurses remain.  The aging workforce, the lack of career opportunities, and the generally poor support for nurses all contribute to the retention challenge.  General practice nurses are funded via the core general practice contract, have no direct influence on the contract negotiations and are not part of agenda for change, and the inequity of pay this generates is the source of much frustration.

PCNs have not helped.  Many nurses are angered by the lack of mention of general practice nursing in the PCN documentation, in particular in relation to the additional roles coming in via the PCNs.  It makes already undervalued nurses feel even more underappreciated, while other professions brand new to the sector receive all the support and attention.

Nurses have provided the frontline of face to face care in many practices during the pandemic.  While many clinical staff were able to function through the use of remote consultations, it was often nurses who had to continue the face to face work such as immunisations and vaccinations, right at the time when the situation was at its worst.  The Queen’s Nursing Institute’s General Practice Nursing Report published last year includes many individual examples of this, and there is no doubt that many GPNs felt exposed to increased risk compared to other workers.

Where does all of this leave the profession now?   Ironically, the introduction of the other roles, and the challenges associated with this, has reinforced for many GPs the value of GPNs.  It is a source of frustration for GPs as much as the nurses that they cannot use the ARRS funding to strengthen this particular workforce.  Despite this, there should still be a place within PCNs for practices to consider how they are supporting their nurses alongside the other roles.

The nurses themselves also have a role to play.  Mel Lamb, a recent podcast guest, describes the need for a change in mindset from the nurses themselves to be more proactive about the opportunities that do exist, and to take more of a leadership voice in how general practice operates.  We have seen the emergence of the Institute of General Practice Management in the last year creating a national leadership voice for practice managers, and it does seem that a similar kind of unifying impetus is needed for GPNs.

National support and action is also required.  It is impossible to look at where we are now, review the progress made over the last five years and decide the job is done.  It cannot be left to the discretion of local areas to determine whether any more action is taken.  There has been some great work started via training hubs, federations and other organisations and these need to continue to be supported and funded, alongside a proper focus on how this critical staff group can be retained, to ensure any gains made are not lost in the next five years.

What to Make of the New PCN Guidance

NHS England has recently published new guidance for PCNs, which covers the requirements for PCNs in relation to the DES specifications and how the Investment and Impact Fund will work for the 18 months from October.  This week I explore the implications of this guidance for PCNs.

Additional funding for PCN leadership and management support (£43m this year) is announced.  While PCN Clinical Directors certainly need more management support to help them with the role, this funding has to be taken with two important caveats.  First, there is no indication as to whether this funding is recurrent or not, and second there does not appear to be any extension of the additional Clinical Director funding itself (which had been increased for the first 9 months of this year).  So rather than “additional funding” it could probably be more accurately described as a re-badging (and reduction) of funding that PCNs are already currently receiving.

What is certainly good news is the announcement that PCNs will not be expected to deliver all of the additional PCN DES service specifications from 1st October, as had previously been signalled.  PCNs have to start with two: CVD prevention and diagnosis and tackling neighbourhood health inequalities.  Even these have been given an 18 month implementation timetable, meaning that the requirements for the first six months are not the full specifications.

Alongside this, the guidance announces the requirements for the anticipatory care and personalised care service specifications for 22/23, meaning PCNs are able to prepare for these now.

Of course the question all along has been where the funding for the additional work in each of these specifications is coming from.  What has become clearer with this publication is that the Investment and Impact Framework (IIF) is intended to provide direct funding support (or ‘incentives’ as NHS England like to term it) for the specifications.  Previously just over £50M had been allocated for the indicators in the IIF from April, but now new indicators have been added from 1 October that take the total national investment to the previously promised £150M.

As an aside, I find talking in these national, aggregated figures extremely unhelpful.  I understand it works for politicians and national figures when they are trying to demonstrate they are investing in general practice, but what a PCN needs to understand is exactly what it means for them (or even for an ‘average PCN’).  The original (£50M) IIF funds meant just over £40,000 was available to the average PCN, and this effectively triples that now this year to just over £120,000 for the average PCN.  In 2022/23 the total available increases to £225M, or £180,000 per PCN.

In the revised IIF there are a total of 666 points now available in 21/22 across 19 indicators.  This jump from just 6 indicators at present will need managing by PCNs.  80 of these points are allocated to the CHD specification (i.e. around £14,500 per PCN) and 56 to the health inequalities one in 21/22 (around £10,000 per PCN).  This does stand in contrast to the 222 points allocated to improving access to primary care services (or 166 if you don’t want to double count the health inequalities indicator, although even that indicator is not about tackling health inequalities per se, but rather health inequalities specifically in relation to access to GP services).

This latest guidance highlights that the focus on access to general practice is firmly back on the agenda.  I am not sure it ever really went away, but PCNs took primacy over access in national policy making for a couple of years, but we are certainly seeing it make a comeback now.  NHS England have produced this chart that summarises ‘PCN objectives’ for the next 18 months, and out of nowhere ‘improving patient access’ has appeared as one of the top 5 objectives for PCNs.  At the same time, supporting and sustaining core general practice is notable by its absence from this list.

Guidance had been promised on the transition of commissioning extended access services from CCGs to PCNs in the “summer” of 2021.  This letter states that this will now be available in “autumn”, but the deadline for the transition remains as April 2022.  This guidance was due last year, and has now been put back again, so it is clearly proving difficult to agree.  NHS England is probably stuck between a rock and a hard place with the government demanding more and more in relation to access, and the GPC unwilling to agree that PCNs will deliver more for less.  In the meantime PCNs are expected to have “undertaken good engagement with existing providers”, which in the absence of any guidance or indication of funding levels is something of a nonsense.

So that’s it.  There was always going to be a scaling up of expectations on PCNs, and we are starting to see this now.  It will soon be impossible for PCN CDs to manage PCNs on their own, simply because of the scale of the demands and delivery responsibilities upon each PCN.  For PCNs to work they need to do more than just what NHS England wants them to, as they also need to make a difference to their own member practices.  This latest guidance reinforces the need for PCNs to make sure they have they have clearly set their own priorities (so as not to be simply swamped by the national ones) and have the infrastructure in place to meet the ever-expanding requirements placed upon them.

Is General Practice Making the Most of CCG Clinical Directors?

Over the last 8 years a wealth of skills, knowledge and experience has built up within a relatively small group of GP leaders who took on Clinical Director roles within Clinical Commissioning Groups (CCGs).  Now that CCGs are coming to an end, what will happen to these Clinical Directors?

The first thing to say is that some CCG Clinical Directors have taken matters into their own hands and have taken on roles as PCN Clinical Directors, thus cementing their place in the new system.  But there are still a considerable number continuing to undertake their CCG roles whose places are less clear moving forward.

The context this sits in is the shift of the system as a whole from a commissioner provider split to one of integrated care systems (ICSs).  Within ICSs the different providers are expected to collaborate and work together to decide how care will be delivered and how resources will be deployed.  One of those providers is general practice.

Many of the functions of CCGs are transferring directly over to the new NHS ICS bodies.  It may well be that roles have or can be identified within these bodies for the GPs in CCG Clinical Director roles.  But the key question is whether general practice as a whole wants these GPs to be deployed providing clinical advice and leadership across the system within the ‘neutral’ NHS ICS bodies, or to be more squarely deployed as part of the leadership team of general practice?

Within CCGs GP Clinical Directors have an explicit remit as GP leaders within GP membership organisations responsible for the health of the whole population.  Within an NHS ICS body, it is less clear that any clinical leadership role should be filled by a GP.  They could just as legitimately be filled by clinicians from anywhere across the provider landscape.

If general practice is to genuinely operate as an equal partner with an equal voice within ICS discussions, it will need leaders who are able to develop strategy, think strategically, and operate politically.  These are exactly the skills that CCG CDs have been developing over the last 8 years, and are not skills that commonly exist amongst the provider-based GP clinical leadership teams.

The Consultant leadership within an acute trust is primarily deployed in medical and clinical director roles within the hospital.  It is only when these roles are filled that it will start to consider supporting system roles.  General practice is in danger of having this the other way round: making sure the system roles are filled before ensuring it has the internal leadership skills and expertise it needs.

History is, inevitably, getting in the way.  GPs who have undertaken CCG Clinical Director roles are sometimes perceived as being distant from core general practice, particularly when they may have been on the commissioner side of developing services and specifications that practices may not have been happy with.

Equally funding is a barrier.  CCG Clinical Directors were well remunerated for their time, and there is no obvious source of remuneration for GP leaders outside of the PCN Clinical Directors at present.

But general practice in every area needs to think through how it is going to be effective in the new world of ICSs.  CCG CDs are a hugely valuable resource for general practice, and the service as a whole would be well advised to consider how it can ensure that this resource is deployed where general practice needs it, rather than passively allowing the system to decide where it should go.

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