Is it time to go “all in” on PCNs?

What is going to happen with Primary Care Networks (PCNs) at the end of the 5 year PCN DES?  Are PCNs going to be a here-today-gone-tomorrow phenomenon, or are they here to stay?  And does it matter?

I think this is a really important question.  It is important because the answer should probably shape how practices approach PCNs, and determine the amount of effort and engagement they put into them.

There are some significant clues in the recently published update to the GP contract.  The update states that the additional roles employed under the PCN DES, “will be treated as part of the core general practice cost base beyond 2023/24” (1.20).  This means £1.13M of additional roles funding (for the “average” PCN) will at that point become part of the core contract.

The Investment and Impact Fund (think QOF for PCNs) will be worth £300M by 2023/24 (£240k per “average” PCN).  This is going to provide population based coverage at a meaningful level within an Integrated Care System in a way that the individual practice QOF does not.  Would it be a huge surprise if future additional investment focussed on the PCN IIF rather than the individual practice QOF?  It would be more of a surprise if it didn’t.

Of the 45 pages containing the details of the updates to the GP contract, virtually half (22 pages) is dedicated to PCNs and PCN initiatives.  The main changes to the GP contract are already now coming through PCNs.  With all the effort and resource that has gone into establishing PCNs and creating them as a platform, it seems highly unlikely that at the end of the 5 years they will be stopped.

More likely is that as the funding for the additional roles shifts into the core general practice contract, so PCNs themselves will shift from being an optional additional service to a core part of the contract.  Despite the nervousness around PCNs that the publication of the draft PCN DES specifications raised earlier this year, the final update reads as though practices and PCNs are already inextricably linked.  And if not now, they certainly will be by 2024.

If you believe this to be true, what does this mean for an individual practice today?  I think the implications are significant.

So far it has been possible to treat PCNs as an optional extra, something a practice can dip in and out of, and leave the work to those prepared to volunteer to take it on.  The implications of the shift signalled in this year’s update are that this level of engagement is no longer going to be enough, because letting PCNs develop in ways that don’t support your practice could jeopardise your practice’s future in the medium term.

Practices are going to have to work to ensure that they are directly receiving the benefit of the new roles and the new sources of funding.  They can’t leave it for others to sort out, and rely solely on the income they receive directly (i.e. not via the PCN).  Over time the PCN will become more established and the ability to shape and influence it will become less for each individual practice.  Practices need to work now to make sure the PCN is working for them and their population.

If I was a partner of a GP practice, my take on this year’s update to the GP contract would be that now is the time to go “all in” on PCNs.  While last year there was probably sense in taking a watching brief to see how PCNs developed, now I think the time for that strategy has come to an end.  The signals are all there that the future of GP funding is going to come through PCNs, and I would want to be right at the forefront of making that work for my practice and my patients.

What to Make of the Updated GP Contract Agreement

I am not sure how many of you will have read by now the “Update to the GP Contract Agreement 2020/21 – 2023/24” released by the BMA and NHS England last week, but having waded through all 86 pages it is hard to take it all in. There are huge implications in particular for PCNs, who will need to digest the contents quickly to be able to move to action.

First things first. It looks like the big problems caused by the draft PCN DES specifications have been addressed. The biggest sticking point was no extra money to deliver the required extra work, followed by the seeming requirement that all of the additional roles would be used to deliver extra work and not support core general practice, with practices expected to chip in 30% of the funding for the privilege. The draft specifications were also seen as over-prescriptive, stifling local innovation and responsiveness.

This update addresses these issues in some surprising ways. The number of specifications needed to be delivered in year has been reduced from 5 to 3. Only structured medication reviews, enhanced health in care homes, and supporting early cancer diagnosis remain, with the other four to follow next year (two were always planned to be implemented from 2021). PCNs are also to “provide access to a social prescribing service in 2020/21, drawing on the workforce funded under the network contract DES” (7.5, p41).

100% reimbursement is to be provided for the new roles, removing the need for a 30% contribution from member practices/the £1.50 per head. This won’t solve the problem of being able to recruit into the roles at the funding levels available, but it tackles the major issue of sourcing the 30%. 6 new roles have also been added to the list that PCNs can use this funding to recruit from: pharmacy technicians; care coordinators; health coaches; dietitians; podiatrists and occupational therapists.

Importantly, assurances are made that the funding for these roles will continue in the core GP contract beyond 2023/24, and that should practices withdraw from the PCN DES the roles would TUPE to whichever provider takes over the delivery, alleviating concerns about future liability costs.

Access to further funding is also provided for PCNs. The level of funding available to source these new roles has been increased. Where it was, for an “average PCN”, £206k in 2020/21 it will now be £344k. An additional (recurrent) £120 per care home bed per year will be directly provided.

PCNs can also access funds through the Investment and Impact Fund (IIF). This looks like it is essentially a QOF for PCNs. It is a points based system, with a number of areas each with indicators allocated a certain number of points. There are upper and lower thresholds beyond which no payment is made, with a sliding scale rewarding performance in between.

The “average PCN” can earn £32,400 in 2020/21 from the IIF (although it has to declare it will use any funds earned for workforce expansion and services in primary care). This will rise to £240,000 per PCN by 2023/24. There are 8 indicators for 2020/2021 for seasonal flu vaccinations, LD health checks, referrals to social prescribing, gastro-protective prescribing (3 indicators), metered dose inhaler prescriptions, and spend on medicines that should be routinely prescribed.

The challenge, then, for the PCN is first of all to identify its overall delivery requirements for next year (delivery against the specifications, delivery of a social prescribing service, delivery against the IIF indicators, and any agreed local delivery).

Then the PCN in relatively short order has to establish the additional roles it will need to enable this delivery. PCNs are required to produce (and submit) their workforce “intentions” by 30th June at the latest, but will most likely need to be actively recruiting well ahead of this. The document encourages, in light of the additional role reimbursement funding, PCNs to use the (existing, recurrent) £1.50 to appoint a full time manager and increase PCN Clinical Director time so that the growing PCN workload can be managed effectively. Sounds sensible.

It does seem that there are sufficient resources available in the updated contract to meet the requirements it makes, while at the same time leaving some freedom for local developments, delivery and innovation. This was always the key for me as to whether the revised proposals would make sense.

There is of course more in the update that I haven’t touched on. There is a renewed focus on increasing the number of doctors, with initiatives including a new two year fellowship programme for all newly qualified GPs and nurses, a new to partnership one off payment of £20,000 to encourage GPs to become partners, and a locum support scheme to encourage consistent locum working with groups of PCNs.

We may have a new government but access inevitably features. This year all practices will be required to participate in an appointments dataset, and then it is about preparation for April 2021, by when there will be a “nationally consistent” offer developed for bringing extended hours and extended access funding together, as well as a core digital service to be offered to all patients.

A new payment mechanism for vaccinations and immunisations is being introduced over the next two years. This year it will become an essential service with new contractual core standards that practices will be expected to meet, and an item of service payment of £10.06 introduced for MMR 1 and 2. In year 2 the item of service payment will be expanded to other areas, and a new QOF domain for routine vaccinations will be introduced, with the existing childhood immunisation DES retired.

There are, as ever, a few adjustments to QOF, but that is the bones of the changes within the updated contract agreement. I am sure it will take time to take it all in (especially getting our heads round the new investment and impact fund!), but from first impressions it seems that PCNs may well survive the turbulence of the last few months and be able to build a platform from which they can start to make a real difference.

It is Not a Race

I am lucky enough to be in a role where I meet lots of Primary Care Networks in different parts of the country.  One of the most common things they tell me is that they know that they are “behind” where everybody else is.

This is interesting for a range of reasons.  Firstly, if everybody is behind everybody else, who is in front?  The influence of social media is such that when we hear a few PCNs report on what they are doing, our immediate reaction is to think we are not doing that so we must be behind, even without knowing anything like the whole story of what is going on in that other PCN.  By and large we tend to share what we are doing well on social media, not what we are struggling with.

Secondly, what does being “behind” actually mean?  How do we determine if a PCN is ahead or behind?  Is it the extent to which they are meeting the DES requirements, meaning the PCN that has a network agreement, a data sharing agreement, a social prescribing link worker and a pharmacist is ahead, and those that don’t are behind?  I am not convinced this is going to be the best indicator of ultimate PCN success, because it is possible to have all those things in place simply with a level of passive compliance from member practices as opposed to any active ownership.

Maybe it is distance along the PCN maturity matrix that is the best measure of progress?  Just in case you haven’t fully internalised the PCN maturity matrix, it identifies five components of a PCN development journey: leadership, planning and partnerships; use of data and population health management; integrating care; managing resources; working in partnership with people and communities.  Now I wrote back in August about the dangers of a nationally prescribed maturity matrix imposing requirements or expectations on a PCN.  Ultimately each PCN should determine its own purpose, and make its own decision as to what its maturity would look like.

Thirdly, is being ahead a good thing?  If we have learnt anything from the DES specifications it is that showing a little bit of caution may actually be wise in the current environment.

As regular readers will know I am a big fan of Professor John Kotter at Harvard and his approach to change management.  He believes assuming people know that change is needed, and focussing instead on strategy and solutions (like PCNs) is what kills most change efforts.  He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change and make PCNs a success.  There is work for PCN leaders to do to get to this point.

So if PCNs are ultimately an exercise in change management, which is what makes them difficult, then moving too quickly into doing things without spending time coalescing around a shared vision is likely to be a recipe for long term failure.  Meeting contractual requirements, or ticking the boxes on the maturity matrix, are a long way from winning the hearts and minds of member practices and local partners.

PCNs are not a race.  There is no prize for being “ahead” (whatever that means).  Taking time at the start to understand what the PCN is for, and what transformation its members want it to deliver, and building trust across the network (however long this takes) is key to making the most of the opportunity that PCNs provide.

Extending the Primary Care Network

What is a network?  According to that modern day fount of all knowledge, Wikipedia, it is, “a set of human contacts known to an individual, with whom that individual would expect to interact at intervals to support a given set of activities. In other words, a personal network is a group of caring, dedicated people who are committed to maintain a relationship with a person in order to support a given set of activities.”

The key point here is that networks are based primarily on relationships.  So while Primary Care Networks (PCNs) may have originated through a contractual route, that shouldn’t be what defines them.  Rather the connectivity, interactions and mutual support of relationships are their lifeblood, and what will determine the impact they can have.

So far Primary Care Networks have, in the majority of cases, been made up of groups of GP practices.  Practices within a network have been building the relationships between themselves to build trust and enable joint working across practices.

But in the Network Contract DES Specification for 2019/20 it said, “There is no requirement for the Network Agreement that is signed by 30th June 2019 to include collaboration between practices and other providers, but this will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated to reflect the new Network Contract DES Specification.” (p11, 3.6).

If we leave the cloud having over next year’s Network Contract DES specification aside for a moment, then the logic of this requirement is sound.  If PCNs are based on relationships, then to make the maximum impact they need to include all those who can contribute to the cause.

But of course there is another way of looking at this.  The reason why practices were uncomfortable signing the network agreement in the first place was the potential impact on the practice’s autonomy.  Practices didn’t want to be told how they would have to operate by the other members of the PCN.  But at least all the other members of the PCN were GP practices, and so there was a level of shared interest.  Widening the membership to include non-GP practice organisations reduces practice autonomy further (less influence on PCN decision making), with less certainty that decisions made will be made in the best interest of my particular practice.

So there are two factors at play here: impact and trust.  For PCNs to have the maximum impact they need a broader set of relationships.  But without trust practices are going to be reluctant to include new members into the PCN family.

Networks must start with a common purpose (clarity on what we are trying to achieve).  Identifying who can help deliver this purpose and widening the membership to include them is the way to move forward.  Let the shared purpose determine the terms of any agreements that need to be made, but prioritise person to person relationships, because it is only when we trust each other that we can work effectively together to make change happen.

The mistake is going to be starting with the network agreements, ahead of building relationships and trust.

PCNs have the opportunity to establish a new way of working for the NHS.  Instead of the traditional top down, bureaucracy heavy, organisation centric way of working, PCNs can model a new style based on trust, relationships and commitment to a common cause.  Whatever the PCN DES specification ends up saying for next year about extending the membership, how PCNs extend their membership is going to be at least as important as who with.

Is it time to move away from centralised control of PCNs?

The biggest challenge the publication of the PCN DES specifications for next year has created is not so much the detail contained within the documents but the loss of enthusiasm amongst GPs for the whole PCN project.

Before Christmas there was hope that PCNs could mark a new dawn for general practice.  But that bubble was burst when the specifications demonstrated the lack of any national ambition to use PCNs to support the ailing profession.

Wherever the national negotiations end up, it is hard to believe they will restore the hope and energy that existed last year.  But PCNs don’t go from being a good thing to a bad thing overnight, and so it is worth taking some time to reflect on the opportunities PCNs create, regardless of national specifications.

A good place to start is the time before PCNs existed (remember that?).  There were two main trends in general practice, both a response to the pressures the service has been facing.  The first was the introduction of new roles, not to replace GPs but to manage those parts of the (growing) demand that their skills made them best placed to take on.  The second was the move to bigger practices and operating at scale, to develop the resilience of practices and to enable them to embrace any opportunities that develop.

PCNs continue both these trends.  The majority of the funding for PCNs is for the introduction of new roles, and PCNs bring practices together and provide the opportunity for the benefits of scale to be delivered across practices.

The big new opportunity the introduction of PCNs has created is working in partnership with other providers.  One of the rationales for PCNs was to enable the gap between primary care and the rest of the system to be closed, and to bring (in particular) general practice and community services closer together.

For GP practices PCNs create the opportunity to better meet the needs of the local population.  Practices can clarify what part of the local demand they are best placed to meet, and what part of the demand is best met by partners, by collaborations and by network wide services.  Where gaps in service provision exist PCNs can work with local partner organisations to fill these gaps.

In a world where we didn’t have PCNs what would general practice be doing?  Probably working towards the development of something that looks very much like PCNs…

So the problem is not primary care networks themselves.  PCNs enable general practice to respond effectively to the pressures they face and to better meet the demands they are under.  The issue lies with the PCN DES specifications which seem to be attempting to shift PCNs away from supporting general practice and into the generation of additional work that will make the current problems worse.

But that doesn’t make PCNs themselves a bad thing.  They remain the best hope for general practice for the future.  What has been revealed as the ‘bad thing’ is the level of control the national contract has over PCNs.  Leaving the destiny of PCNs in national hands already looks like a recipe for disaster.  So now may be a good time for practices and local systems to think carefully about exactly how they want to make PCNs work for them, and to exert more local control to restore the confidence of practices that PCNs can still be the path to a bright new future.

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