What are PCNs: joint working between practices, or something more?

There is an almost palpable dissonance that sits between the Primary Care Networks (PCNs) as constituted in the PCN DES, and how they are perceived in the minds of CCG leaders and those responsible for developing integrated care systems.

On the one hand the GP contract portrays the DES as a framework for practices to work together and to secure investment into general practice over the coming years.  The system, meanwhile, seems to think of PCNs as the building blocks of the local integrated care system, with a membership and remit expanding far beyond core general practice.

So who is right? Are PCNs a contractual construct of joint working between practices, operating solely within the framework of the national GP contract, or are they something more, owned more widely across the system and with an accountability beyond the terms of the GP contract?

This question is one general practice would do well to take time to consider, because the implications are far reaching.

A good place to start is the Long Term Plan for the NHS, published just before the new GP contract.  In chapter 1 of this document, which sets the direction for the NHS for the next 5 years, it sets out five major changes to the NHS service model, the very first of which is “we will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community services” (Long Term Plan p12).

How will this be achieved?  Through PCNs. Through the investment of £4.5bn in “expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices… Most CCGs have local contracts for enhanced services and these will normally be added to the network contract… The result will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care” (Long Term Plan 1.9-1.10 pp 14-15).

There are some important points to note here.  First is that, in case anyone is in any doubt, the primary purpose of PCNs is the integration of primary care with the rest of the system.  The contract has been used as a necessary mechanism for setting them up.  How else can you integrate independent contractors?

Second, is that the promised £4.5bn in the Long Term Plan is considerably higher than the £1.8bn promised in the GP contract to support the formation of PCNs.  This is because the majority of investment in PCNs will not be through the core GP contract.  The funding that comes from other sources (which, by the way, represents a huge opportunity for general practice) will, inevitably, bring with it an accountability outside of the core contract, and into the wider system.

The other place to look is the PCN Network Contract DES, which notes the key features of the DES are set out in the Long Term Plan (and so references the points above without explicitly stating them).  It says the DES is subject to annual review and development, and that the focus in 2019/20 is “to support the establishment of PCNs and the recruitment of the new workforce, with the bulk of the service requirements coming in from April 2020 onwards” (Network Contact DES Specification p5).

So this year (the easy one) is about practices working together, and essentially getting ready for what is to come from 2020 onwards.  That is when the shift will accelerate away from core general practice.  The Network Contract DES guidance states, “PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care. To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.” (p16-17).

One of the service specifications coming in 2020/21 is the innocuous-sounding anticipatory care, “The Anticipatory Care Service will need to be delivered by a fully integrated primary and community health team. To support this, from July 2019 community providers are being asked to configure their teams on PCN footprints. The requirements will be developed across the country by ICSs, and commissioned by CCGs from their PCNs. NHS England will develop the national requirements for the essential contribution required under the Network Contract DES.” (p18).  Within one of seven DES service specifications the NHS has effectively announced the full integration of primary and community care!

Back to the original question – are PCNs about contractual joint working between practices, or about integrating all services within a local community?  While today the answer is largely the former, it is clear from 2020 onwards the answer is very much the latter.  There is no real dissonance (other than between the expectations of pace setting system leaders and the reality of where their local networks are).  PCNs are on a journey.  The start of this journey (and where we are today) is joint working between practices, but very quickly this will evolve into joint working between that group of practices and the rest of the local health and social care economy.  This is the DES practices have signed up to, and these are the changes that are on their way.

Primary Care Networks: A Roadmap until the end of June

While many have sat back and breathed a collective sigh of relief that the 15th May deadline was met for the submission of the initial PCN returns, that was unfortunately only the start of the journey.  Some pretty formidable challenges lie ahead.

I am sure some PCNs have a clear plan and are meticulously ticking off actions and making sure everything is sorted as they get ready for the 1st July, when PCNs formally begin.  This is less for those PCNs, and more for the time poor and those who have that feeling there is something they should be doing but they are not sure exactly what! It also doesn’t cover everything you could be doing (if that’s what you need do watch out for Clare Allcock’s wonderful advice on how to accelerate collaborative working in next week’s podcast).  Rather this is designed to help you meet the minimum requirements.

Essentially, each PCN has to complete three key actions by 30th June:

  • Agree how extended hours will be provided at a rate of 30 additional minutes per 1,000 registered patients to all registered patients within the PCN.
  • Ensure appropriate data sharing agreements and, if required, data processing arrangements are in place, using the national template, to support the delivery of extended hours.
  • Ensure the network agreement is completed (including all seven schedules), and signed.

For the provision of extended hours, each PCN will need to know:

  • Does each member practice wish to undertake the delivery of extended hours for their practice population?
  • If any practice does not, is there another practice willing to take the delivery of these hours on?
  • If not, is there a third party who can deliver the services on behalf of the practices?

It is easiest if each practice does their own extended hours, next easiest if there is some sort of buddy arrangement between practices so that they can cover each other, and least easiest if you have to create some new model of joint working across practices.  That is not to say one model is better than the others, only which is easier in terms of the amount of work each will require in the month until the next submission is due.

Now you may be lucky and already have data sharing agreements in place between your practices.  If you don’t, then there is the promise from NHS England of a national template.  Unfortunately, the PCN frequently asked questions states that this is not yet available as it has to be agreed with the GPC.  Watch out for its publication, as you are not going to have long to turn it round and get it agreed by your member practices.

As for completing the network agreement, remember the starting point for each PCN is the mandatory network agreement (here).  This mandatory agreement cannot be altered.  However, there are 7 schedules where additional clauses can be added.  The template for completing the schedules can be accessed here.

I am not a lawyer, so this is not legal advice, but if you had to prioritise you could go with the suggested wording of the national agreement and not worry too much about schedule 2 (essentially this schedule is where you can make changes/additions to some of the mandatory network agreement), and for schedule 6 you could go with the suggested list of insolvency events (it is essentially a list of different events of insolvency that would enable members to take action under the clauses).  The difficult bits you would then have to sort out are:

  • The rest of schedule 1 (you have already done some of it) where you have to say how the meetings will take place, what is quorate, how you will make decisions etc etc
  • Schedule 3 where you outline everyone’s responsibilities in delivering extended hours
  • Schedule 4 where you have to outline all the network’s financial arrangements (how much money each practice is getting and who is going to pay it)
  • Schedule 5 where you set out the arrangements in the PCN for engaging or employing staff, including arrangements for employment liabilities
  • And schedule 7, which is essentially how you will work with any other organisation (e.g. a federation). Top tip here is get them to draft it for you, and then change their version, rather than starting with a blank piece of paper.

I don’t know how many meetings you are realistically going to have with your practices between now and the end of June, but if it isn’t many you may want to find someone to draft a starter for 10 for each of these schedules.  If you can agree 90% of them remotely, then you can use any valuable meeting time to focus on the hopefully small number of areas that are left.

And once you have done all that, you are probably going to need to get a lawyer to look over the final agreement with all its appendices before you can persuade your practices to sign it.   Remember the submission of the network agreement is due by 30th June which (inevitably) is a Sunday, which means the 28th June, which means there is only one month to go to get everything done.  No pressure!

What would be really helpful would be sharing across PCNs of good ideas for improving the agreement between practices, strong additions to the network agreement, and good wording for the schedules.  Anything we find along the way we will definitely pass on.

I hope that is useful.  If you have any advice for over-stretched incoming PCN leaders that I have missed please do get in touch to share.  Good luck all!

Guest Blog – Tara Humphrey – Introducing New Roles

This week we are delighted to feature a useful guide from our old friend Tara Humphrey, founder of THC Primary Care. Tara appears on this week’s podcast talking about the introduction of new roles to Primary Care Networks. You can find that here.  In support of that podcast Tara has provided us with a written guide to the practical stuff you’ll need to know and you can download that by clicking on the link below:

Tara New Roles

PCN Deadline Day: 8 Lessons we have learnt so far

Primary Care Network submission day has arrived!  3½ months have passed since Primary Care Networks were formally announced as part of the new GP contract for 2019.  What have we learnt in the intervening period?  I would suggest there are (at least) 8 key lessons.

  1. PCNs represent the biggest change for general practice in a generation. While PCNs may have started life as only one part of the package that was the 2019/20 GP contract, it has become clear they represent a much more fundamental change for general practice.  Funding flows into the profession are set to shift from being primarily at an individual practice level, to being primarily at a PCN level.  The fates of GP practices within a PCN are set to become inextricably intertwined.
  2. 15th May was an ambitious deadline for PCN submissions. The initial expectation was practices would have their network agreements in place by today, but as the complexity of that particular task became clear the deadline for the full agreement was relaxed to the end of June.  Practices choosing whom to get into bed with has taken most of the last few months (and some may still not be there yet!), and the challenge of defining the nature of the agreement between them still lies ahead.
  3. The lawyers are coming. What wasn’t clear at the outset was how defined the nature of the network agreements between the practices needed to be.  NHS England has produced a “legally binding” mandatory network agreement for all practices to sign up to, but the meat of this agreement has been left to schedules that need to be developed and agreed locally, which will inevitably require lawyers.  It will be hard to keep the focus on trust and building relationships, which is widely agreed to be the most important foundation for a successful network, once the lawyers are in.
  4. Focus has shifted away from the sustainability of core general practice. In the context of the new GP contract, PCNs were heralded as the mechanism for enabling new funding and resources to flow into general practice.  But on top of the legal fees, each new role requires practices to dip into their pockets to finance the unfunded elements, and the funding for extended hours has been cut.  The talk surrounding PCNs has quickly moved towards “system integration” and equally quickly away from the sustainability of PCN member practices.
  5. The gap in funding for new roles is high risk. As practices have picked through the funding of the new roles, they have found that the headline 70% is an optimistic assessment of the national contribution.  This contribution is fixed regardless of the local market for the roles, or the package the network ultimately has to offer.  Financial liability for the new roles, for example in the case of redundancy, also sits with the practices in the network.  Whether all networks take up the offer of the new roles remains to be seen, but it appears increasingly likely at least some will not.
  6. PCNs represent a shift in system GP leadership. CCGs always had the problem that they represented their population not their practices, despite being membership organisations.  The introduction of PCNs coincides with a 20% cut to the management costs of CCGs and a likely move to a wave of mergers, making CCGs yet more distant from local areas.  At the same time PCNs will each hold seats on the integrated care system boards, as the means of providing “full engagement with primary care” (Long term Plan 1.52).  There is a clear shift of power in motion from CCG GP leaders to PCN Clinical Directors.
  7. The role of Federations is uncertain. Federations were conspicuous by their absence from the Long Term Plan and the new GP contract, and it is clear that PCNs are flavour of the month.  It remains to be seen the extent to which PCNs will work together effectively through federations, or whether each PCN will plough its own furrow.
  8. Expectations of PCNs at practice and system level are very different. There are grand plans for PCNs in the Long Term Plan, as the focus of developing place-based care and integrating services around local communities.  But the challenges facing front line GP practices have not gone away, as the recent Panorama programme highlighted.  Practices need PCNs to first support and enable their sustainability, whereas the system expects them to first prioritise delivery of their own plans.  How that tension plays out remains to be seen.

We are still at the very outset of PCNs.  Establishing them may have been the easy step, compared to some of the questions that remain unanswered and the challenges that lie ahead.

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