How the PCN Practice Relationship Has to Change

The focus on access in this year’s contract mean that the relationship between PCNs and their member practices need to change.  The PCN leadership needs to take on a much more supportive role while practices must become more active in shaping the work of the PCN.

Things are different this year.  Despite the government’s claims that it has simply imposed year 5 of the existing contract, the reality is it hasn’t.  They took legislation through parliament to be able to change the core GP contract, which placed a new requirement on practices to respond to contacts made by patients on the day the contact is made (full details here).

What has then happened is that PCN funding has been used to support the change.  The IIF has largely been scrapped, being reduced to just five indicators worth £59 million, with the remaining IIF-committed funding of £246m for 2023/24 now becoming a Capacity and Access Payment.

‘National Capacity and Access Support Payment: 70% of funding (£172.2m) will be unconditionally paid to PCNs, proportionally to their Adjusted Population, in 12 equal payments over the 2023/24 financial year’ (PCN DES).

This is not really unconditional money.  It is money to enable practices to make the changes they need to become compliant with the new terms of the contract (without that ever having explicitly been said).

There are some explicit overlaps, e.g. the contractual requirement for practices to use digital telephony and its inclusion within the PCN access improvement plan.  Indeed, the PCN plan has to, “set out the current position across the PCN, by each practice in the PCN, according to the table below” according to the NHSE guidance.  The capacity and access work of the PCN is (intentionally) inextricably linked to the introduction of the imposed contract changes on individual practices.

The payment of the remainder of the IIF money, i.e. the other 30% of the national capacity and access support payment, is based on the PCN demonstrating improvements made by its practices in this area, e.g. have all the practices scheduled a date to shift to digital telephony, are all the practices accurately recording appointments.

This represents a pretty fundamental shift.  In the past the dynamic between PCNs and practices was essentially one where the PCN led the delivery of work, and this work was supported by the member practices.  For example the PCN had to ensure that all the care homes were receiving regular ward rounds, and each of the practices had to play their part.  Or the PCN had to ensure the IIF indicators were being delivered and each practice had to play its part.  But each time the responsibility lay with the PCN, and the practices had very much a support role.

This feels different.  For one thing, how on the day demand is managed during core hours is very much core contractual work for practices, which up until now had very much been none-of-the-PCN’s-business.  All of a sudden how practices are run has become of mutual concern.  And the funding to enable practices to deliver their (albeit new) contractual requirements is being given to the PCN (via the capacity and access payment), when previously core contractual funding had always come directly to the practices.

For this work, it is hard to see how the common PCN-led, practice-supported model of delivery is going to be effective.  PCNs can’t for example be telling practices how to run their on the day demand, or demanding project plans from each of their practices.

Instead the PCN delivery model needs to change, and become one that is more practice-led and PCN-supported.  There can be rich learning across practices within a PCN as to how they do things and what works and what does not.  There can be mutual support from practices who have introduced digital telephony sharing the opportunities and pitfalls with those doing it for the first time.  There can be practice-led conversations as to how ARRS staff need to be deployed to enable the right range of care navigation opportunities for them to be able to meet their contractual responsibilities, which the PCN can support.

This year’s changes mean the relationship between PCNs and practices needs to evolve, with the PCN leadership taking on a much more supportive and enabling role, creating a sharing and learning environment, while practices become much more active in designing and shaping the specific changes that need to be made.

Is it Time to Make our Practices PCN-sized?

As the direction of travel looks more and more like it is PCN-shaped and geared towards general practice at bigger scale, should practices within a PCN be considering whether remaining as separate entities is really the best course of action?

There are some heavy hints in the Delivery Plan for Recovering Access to Primary Care document that whatever comes next will be a further push to at-scale working in general practice, in particular the rather unambiguous, “Integrating primary care requires general practice to operate at a larger scale either as part of PCNs or at place level” (p41).

Whatever comes next, don’t expect it to be an end to PCNs and a reversion to receiving funding directly at a practice level.  What is clear is that the wider NHS integrated care agenda is seeking to create bigger, more partnership-friendly units of general practice, and this is not going to change simply because PCNs are not hugely popular with core general practice.

We don’t know the detail of what is coming next.  I don’t think anybody does, even NHS England.  But I do think there are some principles that we can be relatively sure of, and these are that whatever changes are agreed (or imposed) they will be supporting at-scale general practice, more local commissioning of general practice (i.e. less via the national contract), and enabling easier partnerships between general practice and other local providers.

What can practices do now?  Is there anything, because the uncertainty as to what is coming next can be stifling, and indeed for many is creating a reluctance to take any action at all.

I think this is a mistake.  What we have is 10 months of certainty, as we know exactly what is in this year’s contract.  By now we know what we are doing with PCNs (by and large), and so there is almost a sense of this year being the calm before the (next) storm. To me this represents the perfect opportunity to make any big or strategic changes that the practice is considering.

What would these changes be?  Well, the most obvious change is for practices within a PCN to merge and become a single practice.  At present the PCN funding, and ARRS staffing, is separate from practice funding and staffing.  Except it is not in those practices that are single practice PCNs.  In those practices what happens is the PCN requirements simply become another part of the practice’s contractual requirements, and the practice is able to use all of the resources (funding and staffing) as flexibly as it wishes to meet the totality of the requirements.

You can listen in to the Swan practice/PCN explaining how it works for them as a single practice PCN here.  It was no accident that the case study used on p41 of the Access Recovery Plan discussing the future of general practice is that of the Foundry – another single practice PCN.

While I understand the challenges that merging practices creates, and the resistance that many GPs have to the loss of individual autonomy that comes with it, I am not convinced that practices can continue to be sustainable whilst PCN funding and core practice funding remain separate.  Bringing the two together feels like a smart move because of how it enables a longer term sustainability for the practice.  It certainly seems preferable to that funding (PCN, or whatever its successor is) being held by an NHS provider, and the practice constantly having to fight to access it (which seems like one of the alternatives being considered).

It is true we do not know what the future holds, and so there is always an element of risk.  But doing nothing also contains risks, and given that we know the funding flow is much more likely to be PCN-shaped than practice-shaped, making our practices PCN-shaped while we still have the chance feels like an option we should be giving much more time to considering.

What do the Changes to GMS Contract Symbolise?

This year the government took the unusual step of laying legislation before parliament to change the core GMS contract.  Why would they do this, and what does it mean for general practice?

In 2019 a 5 year deal was agreed between the GPC and NHS England.  Pressures on the service, in large part brought about by inflation running at over 10%, meant the GPC has tried to renegotiate this contract (without success) in the last 2 years.  The result has been the negotiated terms of the 2019 agreement have been imposed on the service without agreement.

But this year that is not the only thing that happened.  The publication of the core GMS contract was delayed, and it turns out this was because the government laid legislation before parliament to make changes to the core GMS contract that came into effect on the 15 May.

These changes are in relation to access, and stipulate how practices are to respond to contacts made by their patients.  The GPC have summarised the changes here if you have not seen them.

Why would the government choose to take the unusual step of putting legislation before parliament to change the core GMS contract?

We can only speculate as to the motivation, but it may have been because the only way of the government directing general practice is through the contract.  The GPC had refused to negotiate any changes, but (it turns out) it is within the government’s gift to use parliamentary legislation to make any changes it wants to the core contract.

Of course, changes to the core contract are only meaningful if they are enforced by local commissioners (i.e. the ICBs).  The way that contract management takes place does vary around the country, but generally commissioners try and partner with general practice rather than use heavy handed contract management techniques.  An important question is whether this legislative change will in turn lead to a much heavier handed contract management approach by local ICBs.  Only time will tell if this is the case, but more local disputes seem inevitable.

Meanwhile, the legislative change has already (unsurprisingly) provoked a backlash from the profession.  The GPC response has been to reassert their safe working guidance, which is to move to 15 minute appointments, undertake a maximum of 25 patient contacts per day, and to introduce a waiting list system for appointments.   It says, “any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or urgent treatment centres. This is permitted within the contract which says that patients should be offered assessment of need or be signposted to an appropriate service”.

As ever, the combative BBO LMC have been quick out of the gates in offering guidance to their practices.  You can find it here, and it is unsurprisingly defensive in light of the contractual nature of the change being imposed.   They believe the contractual changes, “will likely result in practices diverting extremely large numbers of patients to 111 and A&E for fear of being held in contract breach, due to the unclear meaning of this clause’.

So it is already clear that imposing contractual changes is not going to lead to service improvement.  This has not happened in the past and it won’t happen now.  It is simply creating bad blood, and a hardening of respective positions, when what the service really needs is support.

Much of the reaction to the Delivery Plan for Recovering Access to General Practice has centred on whether the changes will indeed improve access, and is using that as a marker to determine the value of the paper.  But this misses the fundamental problem that creating a focus on access into general practice deepens the discord between what the government consider the purpose of general practice to be (easy access for patients) and what the profession considers its own purpose to be.  If you haven’t already please read Jonathan Tomlinson’s recent publication The Future of Primary Care – Threats and Opportunities, in which he surmises, “The value of general practice is health gain achieved, illness prevented and, holding-work – the supportive partnerships that enable patients with long-term conditions, especially mental illnesses, to keep going”, which, he argues, is undermined by the detrimental impact on relationship-based care that the ‘taskification’ of general practice work across a team creates.

It also sidesteps (ignores?) the key issue of the pressure created by the funding cuts to the service because of the government’s refusal to at least match inflation.  The document itself is clearly not (as it is sometimes referred to) a recovery plan for general practice.  It is explicitly a delivery plan for recovering access to general practice.  These are two different things, and the concern is that one may be at the expense of the other.

The changes to the GMS contract demonstrate the clear lack of a national relationship between the service and the government, and potentially mark a shift towards a more combative, contract-based style of interaction.  This is not good for general practice.  It will inevitably lead to tensions at a local level.  With the GPC talking about industrial action, and NHS England talking about ‘longer term reform’, my fear is things may get worse before they get better.

The Delivery Plan for Recovering Access to Primary Care

Six months after the Chancellor first announced it, the ‘Delivery Plan for Recovering Access to Primary Care’ was finally published.

It is a national document which aims to solve the problem that is access to general practice.  It does this by using the preferred NHS methodology of identifying a one size fits all solution, and then trying doing everything possible to impose it across the service.

This solution is termed ‘Modern General Practice Access’.  What it is is essentially encouraging online contact with the practice using an online tool.  If anyone rings up or walks in the same tool should be used and completed by receptionist.  The forms should then be assessed by a care navigator who should direct appointments to the most appropriate service or team.

The document describes this Modern General Practice Access as having three components: better digital telephony, simpler online requests, and faster navigation, assessment and response (p20).  We have already seen the focus on these areas in the PCN DES.  Practices are all to use the NHS App, introduce digital telephony and there will also be a new group of fully funded online consultation products available from July 2023 (p25).

The model relies heavily on effective care navigation.  Those of you with medium term memories will recall this featured as a key part of the 2016 GP Forward View, which resulted in limited uptake across the service.  Nevertheless NHS England, “will invest in a new National Care Navigation Training programme for up to 6,500 staff, rolling this out from May 2023” (p26).

The problems in general practice run deeper than simply how calls are managed at 8am.  Capacity is undoubtedly a problem.  The document tries to claim that capacity has increased by 44% since 2019 (p10), but of the 34,700 additional staff that are delivering patient care 32,200 are ARRS or administrative staff.  Meanwhile the claimed number of additional GPs (an extra 2,200) includes doctors in training, and the reality is that the number of fully trained doctors has gone down. No additional capacity is provided as part of this plan (forgive my scepticism that simply writing ‘more new doctors’ actually means anything).

There is no new funding.  There is simply funding that has been ‘re-targeted’.  Bear in mind that inflation has not been funded in general practice for over 2 years, which means that at an individual practice level this is all taking place in the context of less overall funding.

There are nods to estates (‘government will update planning obligations guidance to ensure that primary care infrastructure is addressed by local planning authorities as they do for other infrastructure demands, such as education’ p33) and bureaucracy (where they are going to be “Building on the Bureaucracy Busting Concordat”!), and there is even mention of a national communications campaign.  But nothing that makes you believe anything will be any different this time.

So essentially there is no new money, no additional capacity, and nothing tangible.  There is only ‘Modern General Practice Access’ and some contractual changes.  What, then, is the plan for getting this one size fits all solution implemented across the service?

The answer to this come at the end of the document, where we get into performance management.  First, expect NHS England to hold ICBs to account for delivery (“ICBs are accountable to NHS England for the commissioning of general practice services and delivery against the contract”).  Accountability won’t stop there.

Next, a reminder that contractual and financial levers have been put in place, “To reinforce the ICB role as commissioner and in driving improvement, each element of the plan is supported by one or a combination of: (i) a new 2023/24 contract requirement; (ii) a new 2023/24 contractual incentive; (iii) reprioritised national funding; (iv) greater transparency of outcomes at system, PCN and practice level; or (v) the ability to leverage the existing standard trust contract” (p36).  This is code for, ‘we expect ICBs to manage GP contracts’.

Finally there will be ‘transformation support’, in the form of a National General Practice Improvement Programme (p38), which will include an intensive programme to “help practices in the most challenging circumstances or those that simply feel they do not have the capacity or bandwidth to plan a path towards a Modern General Practice Access approach”.  Practices will be selected for this based on “need and ICB nomination”.  It already has a remedial feel to it.

Contract and performance management appears to be the primary route of choice for implementing Modern General Practice Access.  We will have to see how that plays out.

However, even the authors do not think this is not going to solve the challenges general practice is facing.  Instead they frame Modern General Practice Access as the first step in implementing the reforms in general practice outlined by the Fuller Report.  It introduces the next steps by saying that, “Integrating primary care requires general practice to operate at a larger scale either as part of PCNs or at place level” (p42), which suggests quite a specific direction of travel.  It also says that NHS England will, “explore alternative approaches that can work alongside the partnership model and explore additional opportunities to better align clinical and financial responsibilities in primary care” (p42).

Contracts aside, this is probably the most directive document we have seen when it comes to general practice.  One fears it may be a sign of things to come.

The National Influence of General Practice

General Practice is in a difficult place.  Worse is that politically it is being backed into a corner, and without action things are likely to become more difficult still.  What influence does general practice have, and can it impact national decisions about its own future?

In 2019 a five year deal was agreed including above inflation increases in funding for the service, alongside significant new investment via PCNs.  All was fine until inflation skyrocketed beyond 10% and what seemed like a reasonable deal in 2019 with hindsight now looks like a very bad deal indeed.

The GPC arm of the BMA tried to negotiate further increases to match the inflationary pressure, but the government/NHS England response was simply to impose the terms of the previously agreed contract.  This happened in 2022/23, and then again this year for 2023/24.  Last year there was no concrete reaction from the profession, and so far this year there has equally been zero response.

2023/24 marks the final year of the 5 year deal agreed in 2019.  NHS England has already made it clear that should no new deal be agreed then the terms of this current deal will simply be carried forward.  Would the service be able to survive taking a real terms cut of over 5% for a third consecutive year?

Which begs the question of whether a new deal can be agreed.  The behaviour of NHS England and the government in years 4 and 5 of this contract should make the service extremely reticent to enter into another 5 year deal, but one suspects that is what will be on offer.  Once again it will no doubt be front loaded to make the initial offering attractive (or at least more attractive than continuing with the current deal), but the pain will inevitably come as the time of the agreement progresses.

We know from the Fuller Report that the national direction is for PCNs to ‘evolve into’ Integrated Neighbourhood Teams.  This carries with it the huge risk that the additional investment gained over the last 5 years into general practice through PCNs could be lost as that resource is shifted sideways into NHS trusts and out the control of practices.  We also know from the Hewitt Review that the push is to move funding away from the national contract and into local contracts.  More on why that will be ultimately detrimental to general practice can be found here.

So if the service would generally be against another 5 year deal, a shift of PCN resources out of general practice, and a move away from a national GP contract when we know all of these things are most likely on their way, what action is general practice taking nationally now?  While we all hope that behind the scenes furious preparations are underway, at present there is no visible action in train.

What about on the NHS England and government side?  Well, there is the national media campaign against general practice and the ‘inability’ to book a face to face appointment.  Instead of backing the service the government is announcing rescue plans and ‘firm action’ which implicitly lays the blame at the feet of practices.  As a result public support for general practice is at an all-time low.

Then there is the mandate for GPs to publish any earnings above £159,000.  Why would this requirement, that was dropped 3 years ago, be reinstated now?  It seems highly likely to be pre-emptive, so that any complaints the profession make against the proposed new deal when it comes can be countered with a point to whatever the number of declarations ends up being, ignoring the fact that huge numbers are earning less and that their earnings have gone down.  It is not hard to see the government using the ‘greedy GPs simply wanting more’ argument in any public dispute (just look at how they are handling the dispute with the junior doctors).

There is also the insidious emerging national rhetoric that the national GP contract is ‘broken’ and no longer fit for purpose.  It is not evidence based, but the NHS works by acting on whatever the perceived current wisdom is.  It is not an accident that this rhetoric has become fashionable just as the current contract is coming to an end.

So NHS England and the government have been taking active steps to prepare, while it seems the service has not.  There are plenty of actions the profession could be taking.  There could be some visible protest action against this year’s imposed contract.  Even if it doesn’t get anywhere it would be a marker in the sand for next year.  There could be a collective refusal to publish the requested earnings information, because why would you give your political opponent a stick to beat you with.  And there could be some form of concerted media campaign highlighting the growth in attendance numbers, the failure to increase the number of GPs, the impact of the imposed contract on practice staff (etc etc).  These are just a few, and of course there are many more actions that could be in train.

Something has to change.  General practice has to get its house in order nationally.  What general practice is really crying out for is some strong national leadership.  The service needs to unite behind a national figure, someone trusted by the profession and the public alike.  At present this seems to be lacking, and unless this is rectified quickly there could be some very dark days ahead.

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