11
oct
0

Look After Your Physician Associates

Posted by Blogs, The General Practice BlogNo Comments

It is a difficult time for physician associates right now.  The current barrage of criticism from across the media continues to scale up, and being in the midst of it must be extremely disconcerting and isolating.

The current storm appeared to start back in July, when Pulse magazine reported how a practice in North London had decided to stop employing physician associates following an incident in which a patient died after seeing their physician associate.  This incident was then picked up by Labour MP Barbara Keeley, who raised the issue in parliament.

Since then the media criticism of physician associates has been unrelenting (e.g. this, published on Saturday, where a reporter has trawled though the Physician Associate podcast episodes to create a negative story, or this in the ever-unhelpful Daily Mail).

The medical profession has concerns about physician associates.  This BMJ article explains them pretty well, that patients can be confused as to who they have seen, and the amount of supervision required to ensure safe care.  The safety concerns are particularly great in general practice, where the partners are ultimately liable for the decisions made by all of those in their clinical team.  The problem is that the current (negative) media coverage has prompted these concerns to be liberally aired, which in turn has served to fuel the fires.

Imagine you are a physician associate working in general practice in the midst of all of this.  It cannot be easy.  I spoke to physician associate James Catton recently on the podcast about what it is like, and he said, “I have never seen the backlash or the level of issues being brought up across social media that are anti-PA.  It’s been pretty brutal these last few months to see… It’s not a great time to be a PA.  A lot of PAs feel there is sometimes a target on our back at the moment”.

You probably would not know it, but this week (w/c 6/10) is physician associate week.  This was the fanfare surrounding the week last year on the Faculty of Physician Associate’s website.  This year there is nothing.  Unsurprisingly physician associates want to keep a low profile.  So just at the time when normally there would be some additional national support there isn’t any.  Just the constant media criticism.

Maybe you have your own reservations about physician associates.  That is understandable.  It is a relatively new profession, that still does not have regulation in place, and that is still trying to find its place in the wider health system.

But physician associates are not a luxury.  There are not enough GPs to manage the (growing) workload, and there never will be enough.  In 2016 the government pledged 5,000 additional GPs, and in 2019 this target was upped to 6,000.  Despite a huge investment in training numbers the amount of GPs remains static, as the number leaving continues to match the numbers entering the profession.  In an ideal world there would be enough GPs, but given that is not a realistic possibility different roles are now a necessity.  For its own sake, general practice needs to make these new roles work.

And, ideologies aside, there are people in these roles now – an estimated 2,000 currently working across general practice.  The concerns about their role are largely outside of their control.  They have taken on a role in good faith, and now feel like they are being pilloried for it.  They feel under fire.  They need help, support and encouragement.

Maybe we should approach physician associate week differently this year.  Maybe it should be about taking time out to provide some support to those physician associates that are working with us, to say that we recognise the personal challenge the current situation must present, and to let them know their efforts are appreciated.  A little support now could go a long way in future.

4
oct
0

General Practice Funding

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One of the challenges that representatives of general practice are often given, whether it is explicitly or implicitly, is to increase the funding general practice receives.  But are they going about this the right way?

The system is pushing for more and more of general practice funding to come via Integrated Care Boards (ICBs).  The Fuller report was accompanied by a letter signed by all of the 42 ICB CEOs asking for exactly this, and now Claire Fuller herself has been made Medical Director of Primary Care at NHS England.  It will come of something of a surprise if we don’t see at least signs of this shift when details of whatever is to succeed the current 5 year contract are finally published.

At the same time, many ICBs are now starting to get their heads around their own local enhanced services (LESs), and we are beginning to see changes to how these services are commissioned. The desire for more activity to take place ‘downstream’ (ie outside of the acutes) means potentially more activity for general practice.

What all this means is that the role of the system representatives for general practice is becoming increasingly important, and is likely to have real financial consequences for the service.  But how should these representatives be approaching these discussions?

System funding has for many years been weighted in favour of NHS and in particular acute organisations.  If a hospital trust spends more money than it has then it shows up as a deficit, and funding has to be found to pay for this deficit.  In this way acute expenditure has risen year on year for many years – not because it was agreed in advance, but because during the year more money was spent than was available.

Of course, general practice does not have this luxury.  Liability for any overspend does not revert back to the system, but rather falls on the partners themselves.  The net result is that general practice absorbs its own pressures, right up until practices reach breaking point and have to hand back their contract.

We are in a situation now where there has been activity growth in core service delivery in both the acutes and general practice, but much more of that growth has been funded in the acutes because of the way the system works.  A key part of the issue is that the growth in activity within the acutes is much more visible.  Every A&E and outpatient attendance, admission and operation is individually recorded and reported into the system.

In general practice, this activity remains largely invisible.  Hard as it may be to believe not only does the system not see it, some believe the pressures the rest of the system is experiencing are due to general practice not pulling its weight.

The first challenge for the general practice system representatives is to make this activity visible.  Not additional activity, core activity.  Not as a one off, but regularly and consistently.  Instead of wondering what general practice is up to, the system needs to be as clear on the pressures in practices as they are on those in A&E.

The system has a tendency to look at any growth in general practice funding as requiring something additional in return.  There is always more work attached.  This is the mindset that has to change.  What local general practice leaders need to do is establish that the core general practice workload is both unsustainable and continuing to rise.

This requires organisation, coordination and effective joint working.  General practice representatives cannot do this on their own.  Practices need to work together more effectively with their representatives if they are to exert any real influence into the system.  Because very soon this influence will start to have direct financial consequences for practices.

27
sep
0

Is PCNs running practices the future?

Posted by Blogs, The General Practice BlogNo Comments

An article appeared in the Health Services Journal last week (here, although paywalled) which reported that Hertfordshire and West Essex ICB are replacing the APMS contract with a private provider with a GMS contract to be held by the local PCN.  What are the implications of such a move for general practice?

This is definitely a change in the direction of primary care commissioning.  While we do not know the extent to which this may become common practice amongst commissioners (and it could of course be a one off), it represents quite a significant U-turn from how such events have recently been handled.  Previously they would have either re-tendered the APMS contract or dispersed the list.

It does seem that tendering APMS contracts may no longer be much of an option for commissioners.  There is so little funding in the core contract that the historic providers of APMS contracts are now moving away, for example Centene is reportedly in the process of trying to offload its chain of nearly 60 Operose Health surgeries (formerly AT Medics).  Equally, in this new world of integrated care systems the emphasis is on GP practices working together in PCNs, and many PCNs with APMS providers as members have found it hard to engage them fully in the work of the PCN.  Hertfordshire and West Essex ICB cited the short term nature of APMS contracts, and the challenge this poses to PCN development, as one of the reasons for their action.

In the past some commissioners have sought help from local federations with the running of practices, but these have been almost exclusively APMS contracts.  The difference here is that the commissioner is awarding a GMS contract, i.e. one that exists in perpetuity, to the PCN.

Whilst responsibility for the practice does shift to the other practices in the PCN, it is not the same as dispersing the list.  In a dispersal practices have to take on their share of the patients on the dispersed list, but in this scenario the responsibility (and accountability) comes via their membership/ownership of the PCN.  It does make PCN resources (both clinical and managerial) more directly accessible to the struggling practice which may help, but of course this will equally be a distraction from the core PCN work plus from the PCN support to the other practices.

We have seen practices merging and becoming coterminous with their PCNs, making the PCN work simply an extension of the core GMS work.  But this approach of a PCN taking on a core GMS contract to me is more surprising and unexpected.

Not everyone shares my surprise, however.  Healthcare policy expert Nigel Edwards said “surely it was always the intention”.  Is it inevitable?  Does the current policy environment of integration mean that where we are heading is PCN-shaped or PCN-run practices?  Should we be expecting this to be just the start rather than a one-off anomaly?

PCNs up and down the country vary considerably in their state of maturity.  Some have now reached the point where taking on a practice is a viable option, although many (the majority?) are probably still some way off this.  But the system has been piling responsibility onto PCNs regardless of their ability to take it on, so readiness may not act as any kind of barrier to a roll out of this approach.

But equally commissioners vary.  At the same time as this ICS is awarding a GMS contract to a PCN, another is offering contracts on a ‘branch-only’ basis.  So I don’t think we have reached the point where this now represents the new system approach to commissioning contracts.

It is an interesting development, and one it is worth keeping an eye on to see whether it is a one-off or whether other systems follow suit.  It does seem extremely likely that any new resources for general practice will continue to come via PCNs, and that practices’ dependence on their PCNs will continue to grow.  Whether this then means that ultimately practices end up operating collectively as PCN units, as either a single contract or a collection of contracts held at PCN level, I don’t think is quite as clear cut.  But if we take nothing else away from this is should be that practices operating together as PCNs represents a cornerstone of the new NHS architecture, and it is one that is not going away any time soon.

20
sep
0

What is the Plan?

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When we are trying to understand the future for any individual service (like general practice) it is wise to try and understand what the future for the wider NHS looks like, as a framework to understand any potential changes.  So, what is the plan for the NHS?

The existing NHS Plan was entitled the NHS Long Term Plan, and it was published in January 2019.  While the headlines around it talked about it being a 10 year plan for the NHS, the document itself reads like a 5 year plan.  All of the specific commitments are limited to a 5 year time period, and anything else is described as “and beyond” (e.g. “It provides the framework for local planning for the next five years and beyond” p110).

The NHS Long Term Plan is of particular importance to general practice because it was the document that introduced Primary Care Networks (PCNs).  While there is a tendency in the wider NHS to think of PCNs as a general practice initiative, the reality is they were introduced as a cornerstone of the Long Term Plan ambition to “boost out of hospital care and finally dissolve the historic divide between primary and community care services” p12.

Importantly, PCNs were introduced so that, “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” p6.  As an aside, and regular readers of this column will know is a personal gripe of mine, the dealing with pressures in primary care part of this does seem to get lost in many ICBs’ interpretation of the role of PCNs.

Much has changed since 2019.  Matt Hancock has gone from being Secretary of State for Health to appearing in Celebrity SAS.  Simon Stevens has been replaced by Amanda Pritchard as Chief Executive of the NHS.  Covid happened.  We are now only 6 months from the end of the 5 year planning horizon indicated by the Long Term Plan, and from the end of the agreed period of the PCN DES.  Is the plan published in 2019 still the one the NHS is working to in September 2023?  Are PCNs still the plan to dissolve the divide between primary and community care services?

What the Long Term Plan was actually signifying was a closing of the internal market chapter of the NHS, that had been running since 1990.  It heralded the legislative changes that marked this closure, along with the formal creation of Integrated Care Systems (ICSs).  The new post-internal market system of ICSs is one based on collaboration and one that seeks to “deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care” (p10).

The fact that since the Long Term Plan was published Claire Fuller was asked to produce a document entitled “Next Steps for Integrating Primary Care” tells us a number of things.   It tells us the overall ambition to break down the perceived divide between primary care and both community and specialist care remains firm and an overriding priority.  It also tells us that the progress towards this so far via PCNs has been deemed as insufficient.

Meanwhile the NHS finds itself in something of a predicament.  The usefulness of the 2019 Long Term Plan has effectively run its course (or will have by March next year), and nothing yet has been produced to succeed it.  A general election is due before January 2025 (and therefore will probably take place next year) which makes the publication of any major new NHS plans (such as a new five year forward view/long term plan) unlikely in the intervening period.

So in this period of limbo most likely is that the status quo will more or less prevail, hence the widespread predictions for a one year rollover contract or similar for general practice next year.  When we look beyond that, the big strategic goal to bring primary care and community care closer together is highly unlikely to change.  This means more (not less) focus on groups of practices working together at PCN/neighbourhood scale, more focus on those groups working with other agencies across those neighbourhoods, and a continued shift away from any kind of focus of working at an individual practice level.

13
sep
0

Why Is Practice Sustainability Being Ignored?

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When even private providers start backing out of delivering the GP contract, as now Operose Health has done, it does point to a lack of sufficient funding in the contract.  Indeed, it begs the question as to how GP partnerships are able to make a living from the resources that are on offer.

The sustainability of GP practices is more precarious than it has ever been.  The 2019 contract has not served practices well, as it did not provide sufficient funding to cover the inflationary increases of recent years, and most practices are not set up to be able to make the most of the additional resources which are all going via PCNs.  We are now seeing real financial challenges biting in many practices.

The last time this happened in 2016 there was a national response in the form of GP forward view, which did inject some much needed additional funding into the service.  At least the government and NHS England felt the need to act.  Worryingly, we are seeing no such signs now.  The final 2 years of the 2019 contract were imposed on the service by NHS England.  Zero concern has been shown for the financial challenges this would inevitably cause practices.

Why is this situation being allowed to develop?  For as long as I can remember there has not been an imposed, non-agreed contract for general practice, and then suddenly we have two in a row.  What is behind this unwillingness to fund core general practice properly?

I can only hypothesise as to the cause.  The only reasons I can think of are these:

  1. The government may believe general practice has been overfunded. There exists a school of thought that general practice made money out of Covid and the vaccination programme in particular, that the 2019 contract has invested significant funds into the service at a time when very few areas were receiving any new funding, and that additional resources given to practices serve only to line the pockets of practice partners.  It may be that there are some in senior office who, incredulous as it may be to those trying to keep practices afloat, are genuinely holding onto this as a belief, which in turn has led to the lack of any additional monies coming into general practice.

 

  1. Policy makers may believe by squeezing funding at an individual practice level they can force practices to operate at larger scale. The Fuller Report action on supporting sustainability of primary care states, “Support primary care where it wants to work with other providers at scale, by establishing or joining provider collaboratives, GP federations, supra-PCNs or working with or as part of community mental health and acute providers” p36.  Maybe we have entered an era of stick not carrot for practices to operate at a larger scale, by reducing funding at the level of the individual practice and making the need for shared services unavoidable.

 

  1. It may be part of an agenda to nationalise general practice. We have seen politicians of both persuasions in recent months declare that the partnership model is coming to the end of its life and that new options need to be introduced. Equally we know that the NHS cannot afford to buy partners out of their existing contracts, and so maybe the plan is to make delivering the existing contract so unattractive and so financially difficult that they create an environment in which partners will choose to willingly give these contracts up.

 

  1. The centre may want to reduce the amount of funding that has to be transferred to ICBs when general practice funding shifts from national to local. Now there are some pretty big ifs included in this, but we know that the push from the Integrated Care Boards is for general practice funding to come via them (as evidenced by the Fuller Report and accompanying letter) as opposed to via the national contract.  If NHS England is seriously considering this it is likely to want to ensure the amount of funding it has to transfer is minimised, and so squeezing the contract ahead of any such transfer makes sense.

 

  1. Senior leaders may have confused integrating primary care with the sustainability of core general practice. The Fuller report is striking in that it works to solve a problem that general practice does not know it has (how it is ‘integrated’ with the rest of the system), and explicitly does not concern itself with the level of funding general practice requires (“the existing legislative, contractual, commissioning, and funding frameworks …were out of scope for this stocktake” p27).  Yet when asked what the plan for general practice is, senior leaders will always refer you to the Fuller report.  Somehow the sustainability question may have got lost underneath the current focus on access and neighbourhoods.

I cannot think of any other possible reasons (but do let me know if you can!), so it must be one or a combination of these reasons.  Generally faced with a choice between cock up and conspiracy I generally lean towards the former, as the top of the NHS is not well known for having (never mind delivering) clear strategies.  On the other hand the recent contract impositions and using parliament to enforce changes to the GP contract does seem to signify intention.

Whatever the cause, the reality is that practice sustainability is not a current priority for politicians and senior leaders.  If this does not change in the near future the number of practices getting into financial difficulties is going to escalate.  Maybe that is the point that we will find out the real reason behind the current situation.

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