Is Nationalisation of General Practice Inevitable?

The new NHS obsession is integration.  How can we join everything up so that it better meets the needs of patients?  But could this obsession spell the end of the independent contractor model for general practice?

The shift to integrated care systems is not helping general practice.  The internal market was the prevailing system in the NHS from 1991 when it was first introduced, right through until 2019 when the Long Term Plan was published.  Technically it continued until the new legislation was enacted last year, but to all intents and purposes we have been working under the new system for the last 4 years.

While the internal market was in place the system wanted to find a way to make general practice the “purchaser”.  Numerous different mechanisms to make this happen were attempted, starting with GP fundholding (remember that?) back in the 1990s, right through Primary Care Groups, practice based commissioning and then finally Clinical Commissioning Groups.

But the shift to Integrated Care Systems has stopped all of that. The strategic question the system is trying to answer is no longer how do we make general practice effective purchasers.  Instead the question now is how do we integrate general practice with the rest of the system.

The NHS Long Term Plan proudly states as its number one action in chapter one:

We will boost ‘out of hospital’ care, and finally dissolve the historic divide between primary and community health care

The problem with general practice (according to the system) is that it is too separate, too independent and not linked up enough with community and hospital services.

Plan number one to tackle this problem was the introduction of Primary Care Networks (PCNs).  The NHS Long Term Plan, the first place the idea of PCNs appeared, introduced them like this,

GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff”

I sometimes wonder if the first part of that description (“to deal with the pressures in primary care”) has been forgotten, but that aside it is clear the intention of PCNs is as an enabler of integration.  The original PCN DES stated that after one year a requirement to include collaboration with non-GP providers would be added to PCNs, but then Covid came and this never happened.  Instead the Fuller report (which as you recall was entitled, “Next Steps for Integrating Primary Care”, another clear pointer to the goal the policy makers are now trying to achieve) introduced the idea of Integrated Neighbourhood Teams, as the new souped-up PCN model to enable integration in a way that PCNs so far have not.

But will networks and neighbourhoods succeed in the goal of integrating general practice with the rest of the NHS?  If they don’t then the default is most likely a structural solution.  The structural solution would be to nationalise general practice and make it part of the NHS.  Then the integration box could be considered ticked.

This is why politicians on both sides of the political divide in recent years have suddenly started talking about the end of the independent contractor model.  Sajid Javid when he was Secretary of State got the ball rolling when he claimed in a Times article that nationalising general practice was a way to reduce hospital admissions.  Then earlier this year Keir Starmer said the GP partnership model was “coming to the end of its natural life”.  They, along with certain NHS leaders, are attracted to structural integration solutions because they are clear and can be imposed, even if they do nothing to develop the relationships that are required to make integration effective.

The last we heard there was not going to be any forced nationalisation of general practice.  But the question of how to integrate general practice remains uppermost in the minds of policy makers, and unless PCNs and integrated neighbourhood teams start making more progress soon a heavier push for general practice to be made a full part of the NHS seems inevitable.

5 Key Relationships for PCNs to Review

2024 is going to be a challenging one for PCNs.  The 5 year contract completes at the end of March next year, and while we know PCNs are to continue the pressure upon them is likely to be greater than ever.  Making sure the relationships they have in place now are where they need to be should be a priority for the coming months.  Here are 5 key relationships for PCNs to review.

  1. PCNs and their member practices

Over a quarter of all resources coming in to general practice now come via PCNs.  With all the wage and inflationary cost pressures the future of practices depends on PCNs more than at any point previously, and as we move forward this will become more not less important.  As a result, relationships can go two ways.  Either practices can start fighting with each other and the PCN leadership in a desperate bid to secure the resources they need, or practices can work together and attempt to make the most of the opportunity the PCN presents.

Practices within a PCN can ill afford to be at each other’s throats.  PCNs will increasingly have to take on the role of representing their practices in system discussions.  Rightly or wrongly, more and more the system is looking to PCNs as the unit of general practice that it wants to deal with.  Obtaining the best possible outcomes will require the practices within each PCN to be working together.

  1. PCNs and their local federation

I understand that not every area has a federation in place, but for those who do they could be a really important asset in the coming years.  The Fuller Report has pointed to the infrastructure underpinning PCNs and Integrated Neighbourhood Teams needing to be scaled up to be of the quality required in terms of HR, estates, finance and technology.  The local federation could be the provider of this infrastructure and the enabler of general practice controlling its own destiny.

The alternative is that the support for the PCN will be provided in future by one of the local NHS trusts.  With what I would euphemistically call “structural integration solutions” being very much on the agenda for general practice at the moment (i.e. making practices part of NHS trusts), then this would be a very risky road to travel down for those committed to a future for independent general practice.

  1. PCNs and the other local PCNs

It is hard enough for the practices in a PCN to all get along, never mind all the PCNs in a local area!  But the reality is that moves are afoot to shift more and more decision making about general practice, and potentially resources, from a national to a local level.  When this happens general practice in a local area needs to have influence and be able to speak with a united voice to ensure that any deals that are made locally serve the best interests of the practices and their patients.

But this requires PCNs to be able to work effectively with each other.  There need to be trusting relationships in place, an ability to represent each other in system discussions, and a way of making decisions together.  This takes time, and so time is running out to get this to where it needs to be.

  1. PCNs and the local system primary care group

System primary care groups are odd creations.  In many places they have been formed by the system rather than by general practice, the agendas are set by the system teams, and the membership is generally appointed rather than representative.  Yet the likelihood is that these groups will be the place where decisions about general practice  are made, which could have huge resource, workload and strategic implications for PCNs and practices in future.  Now is the time for PCNs to review whether these groups are working, whether their voice is really being heard, and to push for changes so that these groups are fit for purpose moving forward.

  1. PCNs and local community providers

For the last 18 months the spectre of integrated neighbourhood teams has loomed over PCNs, with the Fuller report saying that these are what PCNs would ‘evolve’ into.  But more and more it is becoming clear that PCNs will be the general practice partner within these new teams, rather than them being a new future for PCNs themselves.  That said, the system focus remains very heavily on bringing primary and community care closer together, and so PCNs getting on the front foot in building these relationships will put them in the best possible place as these new teams develop.

The Changing Role of the PCN Clinical Director

Four and half years into PCNs and it is no surprise that in that time things have not stayed the same.  One thing that has changed more than anything is the role of the PCN Clinical Director.  But has it evolved far enough?  What does the role need to be going forward to ensure future success?

When PCNs first started the role of the PCN Clinical Director was very much about start up, about getting the practices engaged in the PCN and enabling the PCN to take its first steps as a collective unit.  A whole raft of seemingly endless recruitments followed, liberally interspersed with responding to a global pandemic, setting up a vaccination programme, and an ever-increasing set of demands upon these fledgling organisations.

For much of that time the focus of the PCN Clinical Director out of necessity had to be internal.  In many PCNs no other capacity existed, so for anything to get done it was down to the PCN Clinical Director to do it.  But over time, gradually, this has changed.  PCN managers have been appointed, and more recently these have been supplemented by more senior Digital and Transformation Leads.  Throw in some administrative support and some PCNs can now even lay claim to having management teams in place.

With the rapid expansion of the additional roles many PCNs have introduced clinical leads, e.g. to look after the supervision, training and development of the clinical pharmacists or the physiotherapists or the social prescribing link workers, or to lead on some of the many operational components of the PCN DES such as the IIF or the new access requirements.  Meanwhile the role of the PCN Clinical Director has been evolving into one supporting this range of management and clinical leaders, as opposed to one directly delivering the work.

Some PCNs are much further down this road than others, but it is an important journey to take.  Looking into the future what practices will need from their PCN Clinical Director is a much clearer external focus.

The future direction for PCNs is to be part of Integrated Neighbourhood Teams (INTs).  As these have started to develop we can see that the PCN is the unit of general practice operating within these local teams.  A key part of these being successful, or making any form of difference, will be the relationships between the different organisations that are involved.  For PCNs this means that someone has to have the time to invest in building these external relationships, and that in most instances means the PCN Clinical Director.

At the same time the ability of general practice to operate effectively as a collective unit within a local area is becoming more important than ever.  Increasingly we are seeing decision making about general practice being shifted from a primarily national locus to a local one.  It is highly likely that in the coming months much more of the funding for general practice and for PCNs will come through local systems.  PCNs (like it or not) are the main units of general practice within an integrated care system, and so the voice and influence of the PCN Clinical Directors will be hugely important.

PCN Clinical Directors need to have the capacity to build the relationships with external organisations and wider local general practice to be effective going forward.  They will not be able to do this if they are stuck managing the day to day operations of the PCN.  While many have started the journey of releasing the capacity of their CD, for many there is still a long way to go.  Getting as far as possible by March next year is likely to be of critical importance both for the future success of the PCN and of local general practice.

What if the PCN DES was commissioned locally?

One of the potential scenarios for next year is that the funding for the PCN DES will be shifted from the national contract and given to local Integrated Care Boards (ICBs) to commission locally.  What impact would this have?

I should start by saying I don’t know what is going to happen next year, although as I wrote last week we know more than we sometimes think we do.  I don’t have any inside track or knowledge beyond what anyone else has, but based on what we do know it is possible to hypothesise about what next year might bring.  So to be clear this is a thought experiment on what might happen, not a statement about what will happen.

We know the system is pushing for is greater local control of GP funding.  While there have been some ideas floated previously around QOF potentially being commissioned locally, it would seem to me that a much more likely target would be the PCN DES.  PCNs are the basic unit of integration for local systems, and as such it would actually be surprising if systems did not want more control over them.  PCN DES money is not technically core contract money (despite it now constituting more than a quarter of all funds coming into general practice), and so it may actually be easier to shift to local control than other parts of the contract.

What would happen if such a change was to occur?  The first thing we would see would be an increase in variation across the country.  The national contract brings a degree of standardisation which would be lost with such a shift.  We would most likely see some areas add additional local investment to the PCN DES pot to accelerate the local development of PCNs and the shift to neighbourhood working, while others would most likely view it as another source of funds that could be accessed to cut costs so that the system could get closer to its financial savings targets.

We would probably also see variation in how the PCN DES funding is treated.  Some ICBs would understand the funding to be primarily general practice funding, and be mindful of the role this funding plays in supporting the sustainability of general practice.  Others would see the funding as system funding for neighbourhoods, with general practice being only one part of what constitutes a neighbourhood.  One suspects in those areas it would not be long before the resources within the DES started to be shared across a wider group of providers.

Then there is the ‘infrastructure’ question posed by the Fuller Report.  The report stated that PCNs’ “lack of infrastructure and support has held them back from achieving more ambitious change”.  So where does this infrastructure come from?  According to the Fuller Report this would come from an at scale general practice provider or existing NHS Trust.  Would it be wholly unexpected, then, if ICBs then contracted the PCN DES money via one of these providers?

If you take into account the new provider selection regime, which is due to come in place in the new year (watch out for my forthcoming podcast with Ross Clark from Hempsons for more details on this), then actually making this happen would be relatively easy for ICBs.  Having PCNs being directly contracted by the local community or acute trust does provide the type of structural integration ‘solution’ that the NHS heavily favours.

It all feels like a high risk scenario for general practice.  While it may create local opportunities in some areas, it clearly comes with huge risks.  Of course it may not happen, but it is exactly because scenarios like this are not unrealistic that it is critical general practice in local areas work together to develop their local system voice and influence.  This way at least it is in a position to mitigate some of the bigger risks that such a change would cause.  Even if it does not happen next April the chances are high that this will come at some point, and so being prepared is essential.

Tackling the End of PCN DES Uncertainty

Many PCNs are finding the proximity to the end of March when the PCN DES comes to end a real challenge.  Practices are disengaging from the PCN because of the uncertainty as to what is coming next, and it is difficult for PCN leaders to coral the practices into any form of collective action.  Given this situation is a period of limbo inevitable, or can a more productive use of the time remaining be found?

Well the reality is that we are not surrounded only by uncertainty.  There are some things that we do know.  We know that next year there will be a one year “stepping stone” contract, in which we will see a continuation of PCNs more or less as they are, along with some “pointers” as to what may be to come.  There will be an election next year, and so any major changes will not happen until after a new government is in place.

We know that the funding for the ARRS roles will continue.  While we do not know exactly the form that this will take, given that PCNs are to continue then most likely is that the ARRS funding will also continue more or less as is.

We know that there is not going to be any backtracking on the funding for general practice that comes through PCNs.  At present over 25% of funding comes via PCNs, and because the system’s number one goal is to “integrate” general practice with the rest of the system then it is not going to revert from 1250 units (PCNs) to 7000 units (practices).  It simply is not going to happen. We also know financial pressure on individual practices will continue, and there will not suddenly be more GPs.

We know that what is coming next is going to be some version of PCNs working more closely with the other health and social care providers in the local neighbourhoods.  The original PCN DES back in 2019 said that the DES would be “amended from 20/21 to include collaboration with non-GP providers as a requirement”.  While this never happened because of Covid, the Fuller report (now de facto national primary care policy) has outlined exactly this in its description of Integrated Neighbourhood Teams, and it has become clear since that PCNs will operate as the general practice part of these teams rather than become them.

We are also aware of a couple of reasonably significant risks for general practice.  There is pressure in the system for more general practice resource to be controlled locally rather than nationally.  It is also likely that systems will seek to access PCN resources for the sole purpose of neighbourhood working, disregarding their additional function of supporting core general practice.  Both represent significant risks if general practice is not able to influence effectively in local systems.

Given we know all these things there are two actions that are sensible.  The first is for PCNs to create their own plan to manage the end of the PCN DES.  This would include getting the relationships between the practices to a place where the opportunity of the PCN can best be maximised by all (see last week’s blog), and freeing up some of the PCN leadership time to both start the process of building relationships with local providers and to engage in work to strengthen the voice of general practice within the local system.

The second is to refresh the vision for the PCN (if there is one).  I have written previously about this, but essentially unless the practices in the PCN have their own vision for what they want the PCN to achieve then the system is highly likely to impose is its own priorities for the PCN.  With the system changes around integrated care and integrated neighbourhood teams this is more of a risk than ever, so it is critical that practices are clear on the direction they want to take together so that they can shape any future changes into this direction, rather than allowing these changes to determine where they are going.

Working together to create a plan that focusses on those things that you can control and on mitigating the biggest risks is extremely empowering.  It is a much better way of dealing with the uncertainty than taking no action and waiting for a new direction to be imposed, and is one that is much more likely to achieve a better result for both the PCN and its practices.

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