How to Make the Additional Roles a Success

We have a strange irony in general practice right now whereby the biggest investment into the service, the Additional Role Reimbursement Scheme (ARRS), is in many places adding to the challenges practices are facing rather than helping.

What is happening is that the burden of recruitment, line management, and clinical supervision, along with the time needed in each practice to make these roles effective, is outweighing the value the new roles are bringing.  This is then exacerbated by rapid turnover in these roles, and the need to constantly start over and over again.

I have written previously on the need for PCNs to plan for the new roles, and also on the challenges associated with introducing them.  But how can PCNs and practices turn this huge investment (£746M this year) to their advantage?

In recent weeks I have been talking to areas that have found ways of making the new roles a success.  What is becoming abundantly clear is these areas have understood that the introduction of the new roles is a change process and have treated it as such, rather than simply recruiting to the roles and expecting the benefits to automatically follow.

What does this mean in practice?

The leading thinker on change at present is Professor John Kotter.  In this Harvard Business Review Article, in addition to outlining the 8 steps of a robust change process, he states 8 reasons why change processes fail.

Read the article for yourself, but my take on the first three of these reasons, as applied to the introduction of the new roles, is as follows:

Error 1: Not Linking the Roles to the Need for Change

Practices are at breaking point right now.  The workload pressures on top of trying to operate in the environment of the ongoing pandemic are making life extremely challenging for many.  What many PCNs are doing is introducing the new roles without being explicit as to how they directly link to this challenge.  Without this link in place practices feel they are making the situation worse not better.

Error 2: Not Creating a Cross-Practice Team to Lead the Changes

The way many PCNs work is that the leadership of the introduction of the new roles is left to the PCN Clinical Director (CD).  They have a PCN meeting to gain sign up as to which roles from the list to recruit, but overseeing the recruitment process and introduction of the roles is left to the CD, who then in turn has to assign line management and clinical supervision roles out across the network.

The problem is that it is simply not possible for someone to successfully introduce a new role into a practice if they are not part of that practice.  A team is needed with a range of individuals, taken from across each of the practices, that is multi-professional (including practice managers, reception managers, nurses etc as well as GPs), to work together to lead the changes to make the new roles a success.

Error 3: Not being Clear what Difference the New Roles will Make

Kotter calls this lacking a vision.  The places where the new roles are working well have a plan in place as to how the new roles are going to make a difference.  They have created multi-professional visit teams to take the burden of visits off practices, or created multi-professional non-clinical teams that can manage the social and non-clinical work that comes into practices, or built prevention teams with a clear plan to tackle pre-diabetes (etc etc).  This is in stark contrast to PCNs who have simply identified the roles they most like the sound of and recruited to them because the money is available, but have not taken the time to create a clear plan as to how these new roles will make a difference.

These are not the only mistakes being made.  All of the errors Kotter outlines can easily be applied to the introduction of the new roles.  The key message, however, is to think of the introduction of the new roles not as a task to be completed, but as a change process that if done well can add huge value, but if done badly will probably make things worse.

The Investment and Impact Fund Year 2

Whilst we are already a couple of months into the new financial year, with so much going on it has been hard for everyone to fully get their heads round the changes to the Impact and Investment Fund (IIF) for 2021/22.  This week I summarise those changes and what it means for PCNs and practices.

I wrote last year about the Impact and Investment Fund when it was first introduced.  You will recall for the first six months of last year the funding was protected as a covid fund for PCNs.  The IIF was then launched in October, in the format of a ‘QOF for PCNs’.

PCNs are yet to receive money earned from the IIF for the last six months of 2020/21.  As I understand it once the figures have been collated nationally, and they have established exactly what an “average” PCN comprises of, PCNs will be sent a draft declaration which they will need to confirm as accurate, or appeal to their commissioner if the figures are wrong.  The amount of time it is taking to pull these figures together suggests there may be trouble ahead in getting final agreement on these figures!

Year 2 of the IIF is nonetheless underway.  The scheme works the same way as last year, with minimal changes.  The prescribing indicators have been dropped (I suspect at least in part to do with the challenges of integrating the prescribing database with the information from GP systems).  This year there are three flu vaccination indicators, the social prescribing and annual LD health check indicators remain (with adjusted thresholds), and there is a new one off indicator of “mapping appointment categories to new national categories” which needs to be completed by the 30th June.

There is £200 available per point (adjusted for list size and prevalence), with 225 points available in total.  The indicators and amounts available for an “average” PCN are below (also see the PCN DES specification Annex D, p103):

 

Indicator No. of points Upper Limit Lower Limit £ available
% patients aged 65+ who received a seasonal influenza vaccination 01/09-31/03 40 86% 80% £8,000
% patients aged 18-64 and in a clinical at-risk group who received a seasonal influenza vaccination 01/09-31/03 88 90% 57% £17,600
% children aged 2 – 3 who received a seasonal influenza vaccination 01/09-31/03 14 82% 45% £2,800
Percentage of patients on the Learning Disability register aged 14+, who received an annual Learning Disability Health Check and have a completed Health Action Plan 36 80% 49% £7,200
% patients referred to social prescribing 20 1.2% 0.8% £4,000
Confirmation that, by 30 June 2021, all practices in the PCN have mapped all active appointment slot types to the new set of national appointment categories, and are complying with the August 2020 guidance on recording of appointments 27 Binary target – all practices to achieve for PCN to receive in year payment £5,400

 

The amount available is roughly double what was available for the last six months of last year (£40,500, compared to £21,500 for an average PCN last year).  A key point to note here is that only one third of the £150M set aside for the IIF in the contract for this year has currently been allocated. The plan is to allocate the rest of it to new indicators to be introduced from 1st October (Covid permitting) with double the value of the existing indicators.  My understanding is these indicators are most likely to be linked to delivery of the new PCN specifications also due to be introduced at that time.

So by the end of the year the IIF is likely to be worth over £120k to the average PCN.  This is due to increase further to £250k by 2023/24.  During this year the IIF will overtake the core funding of £1.50 per head in terms of value to the PCN, and will continue to grow thereafter.

The flu indicators, representing 142 of the 225 points on offer, do not start until September, so at present there is relatively little for PCNs to do, other than to ensure they have effective monitoring and reporting systems in place, to try and get ahead of the social prescribing referral target, and to ensure all practices carry out the appointment mapping exercise.

But this will most likely be the calm before the storm.  The importance of the IIF may be minimal at present, but the values attached to it mean this is likely to change significantly in the second half of the year.  At that point the new indicators alongside the existing flu ones will mean the work really begins.

Training and Development Support for New GP Partners

A few years ago I wrote an outline of a training programme for new GP Partners.  In recent months I have received regular requests from GPs interested in accessing the programme.  Whilst we never set it up at the time, I am working with some great partners to now make this happen.

Below is an updated and adapted version of the original blog:

“Taking on responsibility for a business, for its staff, for its performance, and for its liabilities, is a big commitment. While in the past GPs took it on because that was the established career route for them, that no longer appears to be the case. Increasingly GPs are opting out of being a partner, and taking on salaried, locum or portfolio careers. Even GPs who had previously become partners are now choosing these alternatives.

It is into this environment that we are developing a training programme for GP partners. It is for those GPs who are considering becoming a partner, want to understand better what is involved, and want to develop the skills to be a good partner should they choose to make that step. It is also for those GPs who have already made the decision to become a partner, and want training and development to ensure they can be successful in the role.

The programme will comprise of the following areas.  We will work with participants to tailor it to their individual needs through the course of the programme

Section 1: Internal – understanding the business

Success Measures: What constitutes success for the practice? Is the practice there to serve patients or to make money? What does independent contractor status really mean?

Partnership: What is a partnership; why partnership agreements are important; what makes a good partnership agreement; building a strong partnership team; “last man standing” and strategies for dealing with it.

People: How to lead people, how to manage people (and understanding the difference!); dealing with difficult people (including other partners!); staff appraisals; staff surveys; team meetings; the importance of coffee.

Finances: Partner financial responsibilities; dealing with accountants; understanding cash flow; how to manage the finances.

Processes: Appointment systems: the good, the bad and the ugly; DNAs; workflow redirection; active signposting. How to implement change within the practice.

Property: Understanding premises; types of ownership of property; leases and rent reimbursement; working with NHS Property Services.

Practice Manager: What to expect from your practice manager; how to get the best out of them; understanding the difference between the role of the practice manager and the role of a GP partner; how to know if you need to change your practice manager and how to do it.

 

Section 2: External – understanding the environment

NHS: Understanding where GP practices fit within the NHS; the different structures and types of organisation within the NHS and how they impact on GP practices.

Commissioners: Friend or foe? Understanding the GP contract and how it works; understanding the different commissioners; how to build effective relationships with commissioners.

Regulators: The role of the CQC; surviving inspections

Primary Care Networks: What is a Primary Care Network (PCN); how to build relationships with other GP practices in the PCN; overcoming history and other barriers to joint working.

Integrated Care: What is integrated care?  What is an Integrated Care System?  What does it mean for my practice?  Is building relationships with other organisations, such as community pharmacy, community trust, local voluntary organisations, local council, local hospital important? Who to prioritise; how to do it.

 

Section 3: Future – understanding the risks

Changing NHS: The changing NHS, including the new (2019) GP contract; integrated care systems; and the role of PCNs moving forward.

Strategic Change: Understanding strategic options for your practice for the future; how to develop them; how to implement them.

Practice mergers: When to consider it, when not to, and how to do it successfully.”

 

If you are interested in being part of our pilot cohort which has a maximum of 15 place available, please get in touch (ben@ockham.healthcare). The course will start in September, and will be delivered online.  We will work with this cohort to tailor the programme to the specific needs of those on the programme.  I am hugely excited about taking this forward, and I will share more details as we finalise the programme over the coming weeks.

How Should Your Practice Respond?

It has been a difficult week for general practice.  The main source of the problem has been a letter from NHS England that panders to press criticism by mandating practices to “offer face to face appointments” (implying they have not), and to allow patients to choose whether they need to be seen face to face or not (“practices should respect preferences for face to face care unless there are good clinical reasons to the contrary”).

The widespread anger this letter has caused is not difficult to understand.  Many practices have been uncomfortable with virtual appointments for a long time, but the ‘total triage’ model was mandated by NHS England in the first place as a response to the pandemic.  To then be criticised on the front page of the Telegraph for using it is galling.

The workload itself in general practice has risen to unsustainable levels over the last few months, in part fuelled by the additional demand from the new routes of access.  Practices are already offering face to face appointments (the implication they are not is of itself insulting), but what this does is raise patient expectations to expect an appointment with their GP whenever they want one.  It is GP receptionists who often bear the brunt where these expectations meet reality, and in extreme circumstances can result in vandalism of practices.

This government’s biggest success has been the vaccination programme, the delivery of which has largely been down to general practice.  There is no mention of this in the letter, of the amount of additional work this has put upon practices, or even any acknowledgement of the contribution made.  Any lingering hopes that the role of general practice in the vaccination programme would change the public perception of GP practices have been sadly extinguished by this letter.

So where does this leave general practice?  What is the right way to respond?

The first thing to note is that the letter is overtly political.  The government is obsessed with access to GP practices (and has been for the last 10 years) because it understands the link between access to a GP practice (where so many of the NHS consultations take place) and the overall public perception of the NHS.

Equally the media understand this.  So a story that demonstrates there are problems with access to your GP is a story that demonstrates a government is failing in its handling of the NHS.  The Telegraph in particular has been trying to make a story about access to GP practices throughout the pandemic. Like it or not, GP practices are political footballs.

The temptation is of course to get drawn into working out how to influence the national debate.  Should there be a collective work to rule, a refusal to participate in any work beyond the core contract, or some other form of collective action?  The unfortunate reality is that for most of us engaging in the national politics around this is futile.  Clearly there is a role for the BMA and GPC in fighting the corner of general practice, but this needs to be done at a national level.  The worst outcome is to penalise your own patients and population because of national politicking.

For individual practices it is better to focus on those things you can influence, such as supporting staff, promoting thank you letters and the positive comments received, building positive local communications about the work of the practice as well as its role in the vaccination programme, and the impact you are making on local lives.  General practice remains one of the most trusted professions in the land, and local people will listen to you.

The bigger question is to work out how you will tackle the next 5 years.  The workload will continue to grow, patient expectations will continue to accelerate, and the number of GPs remains static.  Practices need a plan, because carrying on doing the same things will simply mean the pressure will get worse.  This will not be the last letter, or the last insult, or the last criticism of general practice.

Of course there is the temptation to simply walk away, and say enough is enough.  But not everyone has that option, and all that will do is make it even harder and more challenging for those left behind.  Even if that is what you want, it is better to leave with a clear plan in place so that those who remain have some hope and confidence in the future.

While the independent contractor model means there is limited protection from national and press assaults such as this one, it also means GP practices are businesses that can choose how they operate and organise themselves.  It is better to focus on what you can control and spend time working out what you can do to meet the challenges ahead.

There will always be national politics, and general practice will be part of this.  At times like this it is frustrating, disappointing and enraging.  However, channelling your energy into those things you can control, strengthening your own local communications, and planning for the future is the best way to respond.

5 Top Tips for Success as a PCN Manager

Despite no funding for a manager being included within the PCN DES, the PCN manager has quickly established itself as a crucial role.  As PCNs continue to grow in terms of staff and responsibilities, so has the importance of the PCN manager.  But the role does not come without its challenges, and many who have taken it on are finding the going tough.  How, then, can PCN managers make their role a success?

I recently spoke to PCN management expert Tara Humphrey, and out of that conversation distilled 5 important actions PCN managers should take to be successful in the role:

  1. Be Clear What Success Look Like

The challenge facing many new PCN managers is the PCN into which they are arriving has often not made explicit what actually constitutes success for the PCN.  Indeed, in many PCNs, success can mean different things to different people within it.  If the PCN is not clear what success looks like, it will be impossible for the incoming PCN manager to achieve it!

The trick for the PCN manager is not to assume that simply delivering the PCN DES requirements constitutes success.  If it is not explicit, ask those in PCN what success looks like for them.  Listen carefully to the answers.  Play back what you have heard and get sign up from the PCN as a whole.

When you are clear what success looks like, use it as your guiding principle.  When faced with competing priorities or pressures on your time, use how it will impact on the success of the PCN as your way of making decisions.  This will also help you not to feel like a CCG manager or someone adding workload to the practices, but rather someone supporting them to achieve what they want with the PCN.

  1. Form a Strong Partnership with the PCN Clinical Director

The really successful PCN managers are those who have formed a strong partnership with their PCN CD, and are clear on what each of their roles are.  The two need to work as a team, playing to each other’s strengths, and compensating for each other’s weaknesses.  For example, one might be great at building relationships and communicating with the practices, while the other might be better at understanding and distilling the guidance as it comes in from NHS England and the CCG.

The PCN Clinical Director will always retain overall accountability for the PCN’s success, but what actions the PCN CD and PCN manager respectively take to ensure this success is up to them.  Key is that the two of them create a strong partnership and work together, and the better they do this the more likely success will follow.

  1. Build Strong Relationships with the PCN Practice Managers

The practice managers can make or break a PCN manager.  If a PCN manager can build strong relationships with and earn the trust of the practice managers in the PCN, and have open channels of communication through them into each of the practices, their chances of success are really high.  But if they fail to get the practice managers on side they will really struggle to be successful in the role.

I have already seen a number of instances where PCN managers have had to leave their roles because they lost the confidence of the practice managers.  If the practice managers are regularly complaining about the PCN manager to their GPs, who in turn pass on these concerns to the PCN CD, the position is more or less unsustainable.

  1. Decide Whether to Work With or Round the Difficult Practice or GP

There is always one!  I am yet to meet a PCN where there was not at least one GP (or more often than not a whole practice) who is at best disinterested in the PCN and at worst obstructive to whatever the PCN is trying to achieve.  For the PCN manager there are two choices.  Do they invest significant time and effort into getting this GP/practice on side, so that the work of the PCN can progress?  Or do they focus their attention on the other, more willing GPs and practices to ensure that any attempts to derail progress are not successful?

Each situation is different, and the right approach to take in any individual PCN will depend on the local circumstances, but what the PCN manager has to do is work out which tactic is best and then make that approach work.

  1. Communicate More Than You Think You Need To

For a PCN to be successful, it needs to do two things.  First, take actions and make progress towards its goals, and second communicate these actions and successes to its members.  Most PCN managers understand and do the former, but then completely underestimate the importance of the second.  The result is those in the PCN are generally not aware of just how much the PCN has achieved.

As a PCN manager your days are spent on PCN business.  It is easy to think everyone else has the same level of knowledge of what is going on as you do.  But others in the PCN have busy other jobs and are not as immersed in it as you are, and they quickly forget what the PCN is up to.

Communicating via a once a month PCN meeting is not enough.  There needs to be WhatsApp groups (or equivalent) and a regular email update/newsletter (probably weekly) as a minimum.  Some PCNs have gone as far as setting up their own podcast simply to communicate internally where they are up to.

Success breeds success, and using communication to ensure that not only is the PCN successful but that it is perceived as being successful is vital for future and ongoing success.

 

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