A Network of Primary Care Networks?

Is a network of primary care networks (PCNs) a good idea?  What are the benefits, and why is operating a network of PCNs more difficult than it might at first appear?

It is only a couple of months ago that practices divided themselves into groupings along PCN lines, and the scars in some areas are not yet fully healed.  So it is with understandable trepidation that some PCN Clinical Directors are thinking about whether operating as part of a network of PCNs is something they really want to be part of.

The rationale for PCNs to work together is fairly solid.  There are (at least) four good reasons to do it.  First is simply for support.  PCNs are new entities, and many Clinical Directors (CDs) are new to such a leadership position.  By working closely with other PCN CDs, they can make sure they understand what is required of them, how (and whether) to meet the various asks the system is putting on them, and can share intelligence as to how to meet the different PCN requirements.  There is a safety and security in numbers, and operating together reduces the risk of your PCN becoming isolated, of making unintentional errors, or of being singled out by the system.

Second, working together as network of PCNs creates a greater capacity to meet the ever-growing demands the system is placing on this new cadre of leaders.  If one PCN CD can attend a meeting instead of five, the collective group of PCN CDs is better able to manage the workload between them, and protect precious time for building relationships between practices within the PCN.

Third, the collective voice of all the PCNs in an area speaking together is much more powerful than that of any individual PCN.  Indeed, if one PCN says one thing and then is directly contradicted by another, the overall voice of local general practice is weakened and the potential influence of the new PCNs hugely reduced.  But if a network of PCNs can agree a position, it can be hugely influential on the CCG and wider system.

Finally, the level of resources provided to PCNs is small compared to the asks that are being made of them.  By sharing resources, e.g. administration, finance, recruitment, training, HR (etc), the PCN pound will stretch much further, and the benefit to practices and ability to deliver significantly increased.

If the benefits are so clear why, then, is not every PCN already operating within a network of PCNs?  Indeed, why is it that in some places where such alliances across localities previously existed, they have they fallen by the wayside with the advent of PCNs as more formal entities?

Essentially, it is a question of trust.  For example:

  • Do I trust the other PCN CD to speak on my behalf and adequately represent my PCN?
  • Do I trust the other PCN CD not to take advantage of any opportunities for their own PCN, before sharing any relevant information with me?
  • Do I trust that the decisions the other PCN CDs will make are the best ones for practices? Or that if I make a decision that is worse for my PCN but better for the wider group, when the scenario is reversed the other PCN CDs will equally make the same decision?
  • Do my practices trust me to make the right decisions when it comes to the other PCNs? Will they back me if I choose for us to be represented by a different PCN CD? Isn’t it safer to make sure I represent my practices directly?
  • Do I trust that I am getting a fair share of resources that are shared?

With sharing comes a loss of control.  Giving up control in this way requires trust.  The benefits of PCNs working together in a network of networks may be obvious, but without trust it is very difficult for them to be realised.


Mind The Gap!

A gap has developed between CCGs and Primary Care Networks (PCNs).

It is not hard to understand why this has happened.  PCNs formed as a result of the national GP contract agreement, and not as a result of commissioning decisions by the local CCG.  Indeed, many CCGs had local primary care development plans in place involving “localities” that were somewhat derailed by the imposition of PCNs via the national contract. The core funding for PCNs comes through the national contract, and it is the national requirements of the PCN DES that practices that have signed up to meet.

Meanwhile local CCGs and STPs have incorporated PCNs within their overall system development plan.  For many, they are the centrepiece of the out-of-hospital plan for the new system.  PCNs in these plans go way beyond groups of practices, and include a whole range of NHS, community and voluntary sector organisations working together to transform care and outcomes for patients and local residents.

But, frequently, the system has not discussed these expectations with the nascent PCNs themselves.  It has not worked to get any agreement about the role that it would like PCNs to play in the future with the new PCN leaders.  Instead local systems seem to be relying on an assumption that because the national framework agreement exists, the PCNs will then function and develop in the way the local system wants them to.

And so we have a problem.  The expectations the local system has of PCNs (to play its role as defined by the local plan) is significantly different to the expectations local practices have of PCNs (to meet the requirements of the PCN DES).  Throw into the mix the issue of overall sustainability of general practice and where PCNs sit in relation to that (where nationally it is not clear let alone locally) then it is not hard to see why this gap between CCGs and PCNs has developed.

This manifests in lots of different ways.  Take the new roles.  There is a gap between the expectations and issues for practices about the introduction of the new roles through PCNs and those of the system.  Practices are concerned about making up the 30% shortfall in funding, about potential liability for the roles if the funding stops after five years, and whether the roles will create rather than reduce overall GP workload.  The system wants to ensure all of the funding for new roles is utilised, that the new roles support the delivery of local plans, and that moving staff into the new roles does not destabilise any local organisations or departments (e.g. the ambulance service, the physiotherapy department).

At the same time many CCGs are in the throes of merger, and moving into larger organisations more distant from individual PCNs.  Without action it is easy to see this gap getting larger and more problematic.

The need to close this gap is urgent.  Many areas are shying away from an honest conversation between PCN leaders, the LMC, and the CCG because it is difficult to get to a shared place on what is, for example, the future of access hubs given the national framework, or the need for a multi-agency PCN board when there is no current national requirement around this, or even what realistic expectations of PCNs are given their limited capacity.  Too often local systems are over-reliant on an expectation that national directives will close this gap for them, when this rarely proves to be the case.  With the gap widening seemingly with every passing week, this conversation, or series of conversations, is both essential and urgent.

Is the system suffering from “Shiny New Toy Syndrome”?

If you are not familiar with shiny new toy syndrome, it is characterised by the sufferer wanting to own the latest toy and getting hooked on the intense but very temporary high of the ownership, before moving on to something else.  In the short term the new toy always seems to offer some sort of novel nirvana and the hope of short term gains, and the owner is blinded to the obvious shortcomings of that item.  But then, inevitably, disenchantment sets in, and the owner discards the toy and moves on to the next thing.

It seems to me that at present the wider NHS system is suffering from shiny new toy syndrome when it comes to Primary Care Networks (PCNs).  Whatever the current question, at present the answer is “PCNs”.  From “how will general practice be sustainable in the future?” to “how will we sort out out of hospital care?” and right through to “how will we deliver our ICP plan?”; the answer always seems to be “PCNs”.

As happens with shiny new toy syndrome, the system is apparently blinded to the obvious shortcomings of PCNs, most notably that they are brand new, they have very limited (if any) capacity to deliver, they have a large cohort of inexperienced leaders in place, and the relationships they have are very much in their infancy.  PCN development money is not, unfortunately, magic dust that can make these limitations disappear any time soon.

And it does not take someone with particularly well-honed psychic powers to predict that a year or two down the line widespread disillusionment with PCNs will set in, as they fail to deliver “what we expected”.  This will be followed by questioning as to whether the 30-50,000 population was really the right size, and then a new solution (or shiny new toy) will be put in place to replace this one, with equally unrealistic expectations upon it.

Success generally comes by staying focussed over the long term, and not getting distracted by whatever is new today.  The risk is that in the excitement of PCNs the recent good work that had been put in place to turn round the fortunes of general practice may get lost, including:

  • The GP Forward View and the releasing time for care programme
  • The support for individual practices to meet the challenges they face
  • The support for practices to learn to work together in different ways
  • The support for federations and other at-scale structures as enabling entities operating across multiple practices.

These were things making a difference, and you can feel the system losing its appetite to maintain its focus on them because PCNs are the shiny new toy in town.  Of course PCNs are an opportunity to build on the work so far, to enable further investment where it is needed into general practice, and to develop stronger relationships across general practice and between general practice and the rest of the system.  But it is going to take time.  The benefits will only come over the medium to long term, and they will require PCNs to build on the progress to the point at which they were conceived rather than starting all over again.

Right now what is important is that unrealistic expectations of PCNs are challenged both nationally and locally to give PCNs the chance to grow and develop.  The system needs to move away from shiny new toy syndrome and develop a long term commitment to PCNs as they have been configured, accept the real benefits will come some years down the line, and understand that the best way of accelerating this development is to build on the work already carried out rather than starting all over again.

Are you ready for Babylon?

Any reports of the demise of GP at Hand as a result of the new requirements on it from next year are, at best, overstated.  More likely is the threat to local practices will be greater.  The question, then, is how should practices react?

From April 2020 when the number of out of area patients in any CCG area reaches a certain threshold (1,000 patients) the GP at Hand contract will be split and a new practice list will be created with a new CCG contract, where the company will need to provide premises, be part of local networks, and meet all services requirements.

At present GP at Hand exceed the threshold in at least 17 of the 32 London CCG areas, and there are reports that it won’t be long until this is the case in all 32 areas.  And it is not just London.  In February this year NHS England approved plans for the expansion into Birmingham, and only a few weeks ago the company announced plans to expand into Manchester.

While the suggestion is that GP at Hand will need to set up under new APMS contract arrangements I think this is unlikely.  My sense is they will instead seek to “partner” with an existing practice in each of the relevant areas (and rumours abound these discussions are already taking place).  This removes the need for any set up costs, or any of the recruitment problems that new APMS contractors generally face.  And of course, the ‘local practice’ label could accelerate further the expansion of the service beyond its current rate by giving it a credibility that an anonymous national organisation wouldn’t otherwise have.  Patients not prepared to de-register from their existing practice to register with an on-line provider may not have the same qualms about shifting to the practice down the road.

Will GP at Hand be able to find local practices open to their advances?  Given the challenging environment general practice continues to find itself in, it is hard to imagine there won’t be at least some who will find the promise of silver too hard to resist.

The main challenge this creates for practices is they rely on risk pooling and cross subsidy, where the capitation fee for younger, fitter patients funds the cost of caring for elderly and complex patients.  The way GP at Hand operates, as Hammersmith MP Andy Slaughter describes it, “is distorting the way primary care is going to operate by sucking the most profitable parts into a parallel digital system”.

How, then, should general practice respond?  There is going to be limited political support, as the Secretary of State for Health proudly announced at the RCGP conference last week he was a GP at Hand patient.  If the argument isn’t going to be won at national level, it may well fall to local areas to take up the fight.

But can local areas do anything with the prospect of such a juggernaut looming large?  Even though the situation might feel hopeless to some, there a number of factors working to the advantage of local practices:

  • Consistently over 90% of patients say that they trust their GP, and there is not a clamouring from patients to move to a new service. If practices can keep patient satisfaction high, it is unlikely patients will leave en masse.
  • The opportunity now exists for practices to put their own digital arrangements in place. In the new contract practices have to offer online consultations by April 2020, and so practices can significantly reduce the differential between the local offering and the GP at Hand offering.  Practices working together in Primary Care Networks (PCNs) provide the opportunity for practices to do this collectively, in a way that is tailored to the specific needs of their local population.
  • Local practices are embedded in local communities. PCNs provide an opportunity for practices to strengthen these links further, and to create more reasons why being part of a local service is better than being part of a corporate, national service.
  • LMCs have a role to play. There may not be national opposition to the roll out of GP at Hand, but practices need to be making sure their local LMC is mobilising opposition locally. GP at Hand may come in the package of a local practice, but it is up to the local GP leaders to ensure the local population is fully aware of the reality of the new situation.

There are probably lots of other factors that I have missed.  My point is that Babylon is coming, and it is important practices understand what is on the way, and think proactively about what they can do to minimise the impact on their own practice.  The head in the sand approach is unlikely to be the best one, and now is the time for local practices to get together and come up with their own plan to mitigate the forthcoming challenge.

What single thing can have the biggest impact on GP resilience?

I was talking recently to Dr Rachel Morris (who as many of you will know is a Red Whale presenter, coach, and specialist in resilience) as part of a conversation for her new podcast “You are not a frog” (which focusses on how to build resilience and thrive in challenging environments).  General practice is certainly challenging, and the question Rachel asked me was what can GPs do in such an environment?  What “quick wins” are there that GPs can take?

I reflected on all of the guests we have had on the General Practice podcast, and what is clear is that there are no magic bullets for general practice.  Changes that have worked for some have not worked for others.  Some practices hate telephone appointments, some swear by them.  Some love new roles, some think they simply add to the overall burden of work.  Some like to give the admin team more of the GP workload, but others find the lack of control adds to rather than reduces their stress levels.

There is, however, one thing that GPs who are working in practices that are thriving in the current environment have in common: the ability to make change happen.  I don’t think it is over-stretching it to say that a key part of developing resilience for GPs is the ability to make change happen in their own practice.

I recently interviewed Dr Liz Phillips on the podcast, and she talked about the transformational impact being able to make changes (for her as a partner, compared to 12 years previously as a salaried GP) has had on her.  Longer time listeners to the podcast may also remember the inspirational Dr Farzana Hussain talking about how learning how to make change happen using quality improvement techniques had given her the strength to carry on when she was left as the sole partner in her practice.

Resilience comes from the sense of control that when things are not working, they can be made better.  When problems are being faced, there is a way out.  When making change feels impossible, it is easy to understand why individual GP resilience can suffer.

Recently on the podcast Paul Deffley (in a must-listen episode) described his experience of making changes across multiple practices.  However, it was in his first appearance on the podcast that he described an experience of two practices introducing the same pharmacist to do exactly the same things.  One had made it work really well, one hadn’t.  The pharmacist was the same, and what the pharmacist was doing was the same.  The variable was the practices.  Why would one practice be able to introduce the change successfully and the other not?  Ultimately it came down to ability of the practices to make change happen.

Making change is difficult.  But it is not impossible.  Learning how to make change is a skill, and it is one that it is worth investing in developing because the benefits are so wide-reaching.  I remember my own ‘a-ha’ moment many years ago, when suddenly after 5 years of “managing” in acute hospitals I learnt the role was not simply to keep things going, to do the heavy lifting for a period of time until it was someone else’s turn, but to actually make things better.  I learnt the skill of making change happen, and it completely transformed my own experience of being a manager.

So when Rachel asked me what can GPs and practices do that will make the biggest difference in the challenging environment of modern day general practice, my response was to learn how to make change happen.  Whatever the challenges a practice might face, if it knows how to implement change effectively it will always have a route to overcoming them.

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