It is time to bring back face to face meetings

Back in 2019 it was normal for meetings between practices to be face to face.  Protected learning time sessions (or academic half days, or whatever they are called locally) were normally carried out face to face.  But then in 2020 everything changed.  The pandemic meant that face to face meetings were no longer an option, and suddenly every meeting was on Zoom or Teams.

4 years later most PCN meetings are still virtual.  It is much more convenient for practice leads to meet regularly with the other practice leads via a Team meeting than face to face.  There is no travel time and the time out of the day caused by these meetings is massively reduced.  Plus it allows opportunities for multi-tasking when agenda items lack any obvious relevance…

But this is having a negative impact on relationships between practices.  When people are not meeting face to face relationships inevitably suffer.  Maintaining relationships requires at least some face to face meetings.  We know if we need to have a difficult conversation it is better to do it face to face, yet PCNs will often have these conversations in an online environment.  We miss nonverbal communication cues that help us understand what people are saying when we meet remotely (especially when cameras are off!), and as a result misunderstandings and conflict are much more common.

The interpersonal connections that are vital to building trust are missing when we only meet online, and without trust PCNs run into serious problems.  With practices now under such financial and workload pressure relationships are inevitably going be strained, and the virtual meeting environment is making this worse.

Protected learning time events have suffered the same fate.  It is a source of consternation for some that their ICB do not support these, but that aside and for those areas where they do happen the majority still take place virtually.  This used to be the time when all the GPs and practice staff in an area connected, and developed their sense of collective identity.  With the turnover and changes in personnel that we have had in the last five years there will now be many staff who know almost no-one from any other practice outside of their own PCN, because they have not had the chance to meet regularly together.

This in turn creates tension between PCNs.  Whereas previously local GP leaders could cultivate and call on a sense of collective identity, now if a PCN decides to go its own way regardless of the impact on the rest of local general practice there are often no longer the relationships in place to enable sensible local cohesion.

The simple reality is that given the political context that general practice is operating in right now the biggest support available for GP practices lies within general practice itself.  To get through this current set of challenges practices need to stand together and support one another.  By continuing to only meet virtually we are making this harder to achieve, exacerbating tension and conflict within and between PCNs.  So even though it might feel inconvenient it is important that at least some of the time we bring back face to face meetings.

What to make of NHS England’s latest General Practice Initiative?

Last week NHS England announced a new initiative in which it plans to test new ways of working in general practice to “optimise the general practice operating model”. But is there any sense that this initiative will help with the challenges GP practices are currently facing?

There has been a growing divide between the profession and the policy makers, and sooner or later things are going to come to a head.  The issue is that the problems practices want to solve (practice financial sustainably and workload) are not the problems NHS England is interested in.

Let’s start with some recent historical context.  Back in 2016 the GP Forward View was published.  This was manifestly an attempt to support general practice and provide it with the resources and support it needed to recover from the perilous financial position it found itself in at that point in time.

Then in 2019 (3 years through the 5 years of the GP Forward View period) this plan was superseded by the 2019 5 year contract that introduced PCNs.  This promised new investment into general practice in return for practices signing up to form part of PCNs.

The first year of this contract went reasonably well, but then Covid struck.  It was after general practice had been lauded for its role during the pandemic and throughout the vaccination programme that things started to change for the worse.

The PCN money never really found its way through to practices, and then in April 2022 we had the first of what has become three consecutive below inflation contract impositions upon the service.  In May 2022 the Fuller Report was published, which manifestly does not seek to address sustainability issues at practice level but rather how general practice can be “integrated” into the rest of the system, and despite that has become the default strategy for general practice at both a national and local level.

A series of NHS England personnel changes has not helped.  First Simon Stevens, who to be fair to him had always clearly articulated the importance of a strong general practice, left his role as Chief Executive of NHS England in July 2021 and was replaced by Amanda Pritchard.  Dr Nikki Kanani, who had been a strong advocate for general practice and supporter throughout the pandemic, departed from NHS England a year later.  Dr Amanda Doyle arrived as National Director for Primary Care, and Dr Claire Fuller herself was eventually appointed as the new Medical Director for Primary Care in place of Dr Kanani.

So ever since Amanda Pritchard, Amanda Doyle and Claire Fuller have been in post we have had three consecutive imposed contracts, disinvestment in core general practice, and a system focus on integrating general practice with the rest of the system via PCNs, with seemingly little or no concern as to whether practices are able to remain viable.

This is the context into which this new initiative to “test new ways of working in general practice” has been announced. The mindset appears to be one of how general practice can support the rest of the system, e.g. how integrated care teams can prevent admissions to reduce pressure on the urgent care system, with little or no attention being paid to the important direct contribution of general practice itself.

This latest initiative is symptomatic of the recent approach NHS England has been taking to general practice.  It starts with an assumption that the things that need to change are obvious, yet there is clearly a gap between what practices and what the system believe these things to be.  It continues to focus on “integrated neighbourhood teams” with no clarity (either within NHS England or outside it) as to what these are intended to be.  It bypasses traditional lines of communication with general practice (i.e. the GPC), instead choosing to unilaterally announce a series of pilots in a random set of ICBs.  And (as ever) it refuses to provide any funding, instead saying that ICBs should “commit reasonable resource” to the pilots.

So my prediction is that these pilots will end up alongside other recent pilots (multispecialty community providers anyone?) as something that gets talked about for a little while but that are ultimately ignored once policy makers decide what they are actually going to do.  In the meantime the challenges to the delivery of core general practice remain, and unless NHS England appoints leaders who take these seriously it is hard to see this changing any time soon.

The Impact of Practice Financial Challenges on PCNs

This year is going to be tough for GP practices financially.  What will the impact of these financial challenges be on PCNs?  Will PCNs finally come into their own as a (now necessary) mechanism for joint working between practices and enabling economies of scale, or will tensions between practices and PCNs simply rise?

The scale of the financial challenge facing GP practices this year is unprecedented.  The 2% contract uplift takes no account of the rise in the minimum living wage, and the inflationary uplift of 1.65% bears no resemblance to the inflationary pressures practices are facing.  Whilst this is the third consecutive time a contract with real terms cuts has been imposed, it is the first time it has not been at least partially offset by increased investment in the PCN (the funding of which has similarly been frozen).

The impact of these financial challenges will not be limited to practices.  PCNs will also be affected.  When the finances of any organisation come under pressure then there is frequently a knock on impact on collaborative working.

How will practices respond? They will understandably prioritise core activities over any collective PCN activities.  Where resources are limited practices will focus internally and if something has to go then it will be most likely be the PCN work.

The tolerance for ARRS staff carrying out PCN work as opposed to supporting practices with their core work will most likely reduce.  It is already increasingly common to find practices calling for ARRS staff to be allocated on a ‘per practice’ basis rather than working as teams on PCN work.

Many ARRS staff were employed during and immediately after covid which, along with the lack of available space in GP practices, meant that many were employed to work virtually for some or all of the time.  But the usefulness to practices of staff working remotely is generally less than those delivering in-person services, and so now we are seeing a push for less of these virtual working arrangements.

When resources are limited organisations generally become more risk averse.  So while the opportunity for joint working and initiatives for collective benefit via the PCN still exists, the willingness of practices to put time and resource into a new way of working with an uncertain outcome is likely to be less.

Shared ventures require some form of shared overhead in order to be effective.  But practices will increasingly see this as being an unnecessary expenditure, with a growing belief that it would be cheaper (more profitable) for the service to be delivered in house by the practice.  As a result practices who were previously supportive of PCN or federation delivered services (like enhanced access) are now starting to consider providing these services directly themselves.

Financial instability also impacts trust.  When practices doubt whether the other practices in the PCN can fulfil their obligations or contribute meaningfully to shared goals then when times are tough commitment can wane quickly.  Practices that have this sense that they are “carrying” some of the other practices in the PCN are likely to pull back from PCN activities when they come under financial pressure themselves, with obvious consequences for the PCN as a whole and its ability to function effectively.

So the natural tendency of such an environment is to impact negatively on collaborative working, but this does not mean that it is inevitable.  It makes good logical sense for practices to pool resources and to share the burden of financial constraints as together they can achieve more than they can individually.

But PCNs will need to be focussed.  Ignoring the financial challenges faced by member practices will not work.  Instead, PCNs will need to take a much more practice focussed approach to collaboration, focusing on measurable outcomes and making a tangible impact. Activities and investments will need to be aligned with objectives and priorities agreed with practices in advance.

A tough financial environment is difficult for everyone.  Working together in PCNs is a viable strategy for practices to cope with this environment, but it will not happen by itself and PCNs will need to work hard to prevent the default option of practices withdrawing from collaborative work and focussing on themselves.

3 Things to Watch out for in 24/25

Whilst there is not a whole lot of change in the GP contract for next year, there are a few things that are different and worth watching out for.  All the headlines have (rightly) been about the lack of any additional funding, but that doesn’t mean practices and PCNs should not pay attention to some of the changes that have been squeezed in.  I highlight 3 things it would be wise to keep an eye on below.

  1. PCNs to Performance Manage Practices?

One of the changes presented in this year’s PCN DES is that PCN Clinical Directors are now to determine whether the PCN member practices have met the key components of Modern General Practice Access.  It states:

“10.4A.3. The PCN Clinical Director must, prior to 31 March 2025, apply the assessment criteria and determine whether each improvement has been achieved (i.e. whether all assessment criteria for an improvement has been met). When applying the assessment criteria, the PCN Clinical Director must apply the criteria across all Core Network Practices of the PCN.”

This potentially puts Clinical Directors in a tricky position.  Practices will be pushing for them to claim the funding as early as possible, and yet it is down to the Clinical Director to determine whether the practices are eligible.  Without working this through carefully with practices (e.g. how will the PCN make the decision that practices are eligible?) the Clinical Director could unwittingly end up being the performance manager of practices.

  1. How will the Digital Telephony data be used?

Alarm bells are also ringing with the new requirement outlined in the contract letter for practices to provide digital telephony data from October:

In 2024/25 the GP Contract will be amended to require practices to provide data on eight metrics through a national data extraction, for use by PCN Clinical Directors, ICBs and NHS England.  These eight metrics are:

  1. call volumes
  2. calls abandoned
  3. call times to answer
  4. missed call volumes
  5. wait time before call abandoned
  6. call backs requested
  7. call backs made
  8. average call length time

 

While the claim is that this will be used by NHS England and ICBs to “support service improvement and planning” it would not be a huge surprise if the system came down hard on outliers.  What will be interesting will be whether this pressure is exerted on practices directly, or whether it comes via the PCN.

In fact, the subsequent Update and Actions for 24/25 to the delivery plan for recovering access to primary care states,

Our goals for 2024/25 are … for PCNs to review the key telephony metrics across their practices (including number of calls, average wait, abandonment time, average call length) to support quality improvement in demand management and planning of care navigation. …Separately, we plan to share data on the number of calls to 111 in core hours with PCN clinical directors to support quality improvement.”

If “support quality improvement” really means “performance manage” (because that is how NHS England operates), then pressure on PCN CDs to performance manage their practices really does look like it could become a theme for the year ahead.

  1. Neighbourhood Teams: PCN-shaped or community services shaped?

In the 2024/25 Planning Guidance, that was finally released at the end of March, it was no surprise to find access as the priority for general practice.  However, integrated neighbourhood teams also feature, and the guidance states,

As a step to building integrated neighbourhood teams and to support the integration of primary care and community services, we ask systems to help improve the alignment of relevant community services to the primary care network footprint.” p18

There is a heavy scepticism amongst some as to whether in reality this will mean PCN footprints being forced to align to community service footprints (as opposed to vice versa).  Certainly it is something to watch out for, as the guidance is written with an apparent primacy of the PCN footprint.

But this is not the end of it.  The last page of the planning guidance states,

We will work with ICBs to ensure that each system has a plan that shows over 3 years how primary care and community organisations will work to shape integrated neighbourhood teams.” p35

While at present integrated neighbourhood teams appear to be random joint working initiatives looking at specific patient cohorts e.g. frail elderly, patients with diabetes etc, the plan for the future seems to be something more substantial.  “Integrated neighbourhood teams” may actually be a euphemism for general practice and community services operating as part of the same organisation, or at least a structured partnership between the two.  Aligning PCNs and community teams looks like it may be the first step on that journey.

PCN Plus: A Professional Development Course for Leaders of General Practice at Scale

Introduction

General practice is at a transition point.  The 2019 5 year contract has come to an end, the newly imposed 24/25 contract will make things worse, and Integrated Care Systems are prioritising the integration of general practice via the implementation of the Fuller Report.  Practices are struggling to meet the workload and access requirements, and are increasingly coming under financial pressure.

This means those tasked with providing leadership to groups of GP practices, whether within a PCN, a federation, or across an integrated care system are facing a huge challenge.  The need for at scale general practice to support individual member practices, make the most of an increasingly large and disparate workforce, build productive external relationships, and navigate through a constantly changing environment, is making these leadership positions potentially the most challenging roles there are in general practice right now.

There is precious little support available for these leaders.  PCN Plus is a professional development course designed specifically for PCN Clinical Directors, PCN managers, federation leaders and those leading general practice within integrated care systems.  It will help you to develop the skills and understanding you need to be successful in these roles, as well as enable you to become part of a cohort of individuals in a similar position to learn from and with together.  

Who is it for?

If you are a PCN Clinical Director, a senior leader within a PCN, a leader of a GP federation or have leadership responsibility for general practice within an ICS seeking training and development support to better undertake the role, then this course is for you.  It is specifically designed for leaders of at-scale general practice to better understand the requirements of their role, how to cope with it, how to prioritise, how to navigate through all the challenges, and most importantly how to make it a success.  

What outcomes will the course achieve?

This course will provide expert input and teaching, as well as increasing your network of support from the other general practice leaders learning alongside you.  It is specifically designed to help you to:

  1. Develop your understanding of the environment you are operating within
  2. Agree a vision, and clarify and articulate the reasons for working at-scale
  3. Put an effective medium term strategy in place
  4. Build member practice engagement in the organisation 
  5. Make the most of the opportunity of the additional PCN roles
  6. Establish a robust financial strategy
  7. Improve and strengthen your delivery ability
  8. Develop productive external relationships 
  9. Understand and capitalise on integrated neighbourhood teams
  10. Strengthen the voice of general practice within the local system
  11. Improve your chairing, facilitation  and conflict resolution skills
  12. Create a succession plan for the future
  13. Learn from the experiences of others in similar roles

 

What is on the course and how does it work?

The programme will start in June 2024 and run until March 2025 and run across 10 sessions.  Each month there is a live 2 hour teaching and learning session that will take place on a Thursday evening from 7-9pm.  These sessions will cover the following areas:

Session 1 Understanding Integrated Care & Operating within the new system

Understanding different levels of integrated working 

  • Level 1: Between general practice
  • Level 2: Networks collaborating with networks
  • Level 3:Primary care networks and wider community health services
  • Level 4: Primary care networks/ Networks of Networks and hospital/social care services
  • Understanding your network’s maturity
Session 2 Vision and Strategy

  • The importance of establishing a vision
  • How to agree a vision across practices
  • Agreeing, clarifying and communicating role
  • Using the vision to be build practice engagement
  • Revisiting the vision
  • The future of federations, PCNs and at-scale general practice
  • Building a medium term strategy
Session 3 Engagement and Co-production 

  • Building a golden thread between practices, PCNs and at-scale general practice
  • All practice meetings
  • Making decisions
  • Creating effective communication channels
  • Working with disengaged practices
  • PCN and federation relationships
Session 4 Financial principles 

  • Understanding the income streams
  • Practice funded or ICB funded?
  • Prioritising expenditure
  • Budget setting
  • At-scale viability vs practice finances
  • Managing over and underspend 
  • Financial planning 
Session 5 Workforce

  • Building effective support teams for general practice
  • ARRS Recruitment and retention
  • Clinical supervision and line management
  • Team building
  • Hosting multi-disciplinary/multi-agency teams
Session 6 Business management, operations and productivity

  • Delivering benefits of at-scale working
  • Creating delivery plans
  • Implementing change
  • Project management
  • Monitoring performance
Session 7 Integrated Neighbourhood Teams

  • Understanding integrated care and operating in the new system
  • Learning from others
  • Building productive relationships with other providers
  • Hosting integrated neighbourhood teams
  • What’s working well
  • Areas for development
Session 8  Data, Digital and Transformation 

  • Understanding the difference between digital, data and transformation
  • Identifying your data sources 
  • Getting clear on the problem you are trying to solve 
  • Presenting and positioning your information to maximise engagement 
  • Using data to drive continuous improvement 
Session 9 Building General Practice Influence within the system

  • Joint working across PCNs, federations and LMCs
  • Establishing an executive function
  • Setting priorities
  • Representation process
  • Creating a single point of access
Session 10 Personal leadership and Resilience Skills

  • Understanding strengths and weaknesses
  • Chairing and facilitation
  • Creating a complementary leadership team
  • Internal versus external focus
  • Managing conflict
  • Personal resilience
  • Creating a succession plan

 

As well as the live monthly sessions participants will receive a range of additional resources, information and useful materials, as well as access to an exclusive membership community only for programme participants.  

Who will deliver the course?

Experienced PCN Clinical Directors Dr Hussain Gandhi and Dr Andy Foster from eGPLearning, Ben Gowland, former NHS Chief Executive and host of the General Practice Podcast, and Tara Humphrey, an experienced PCN Manager and host of the Business of Healthcare Podcast have joined forces to bring you PCN Plus.  Together they have a proven track record in leading general practices, primary care services and PCN Networks, and have combined their expertise to bring you a leadership programme that speaks to the heart of the challenges and opportunities you will face as a primary care leader in this changing environment.

How much does the course cost?

  • The cost of the course if £3,000 plus VAT per person
  • When completing our registration form you will have a tentative place on our programme, a formal place will only be confirmed after we have received FULL payment of the course
  • No refunds will be issued after a payment is made

How do I book?

To reserve your place, or if you have any queries about the course, please contact Sarah on pcnplus@outlook.com.  The total number of places on the course is limited and applications will be accepted on a first come first served basis.  The deadline for receiving applications is the 31st May 2024. 

 

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