19
jul
0

Are we simply waiting for PCNs to pass?

Posted by Blogs, The General Practice BlogNo Comments

For those who have been around a long time it is hard not to get cynical, as every couple of years there is a new scheme for general practice that is heralded as the big ‘new thing’ but then fizzles out, and disappears as quickly as it arrived.  Are we not headed the same way with PCNs, and so shouldn’t we be keeping our heads down and simply focussing on the day job?

Bear with me as I take a short trip through recent history.  Back in the early 1990s (voluntary) GP fundholding was introduced, but no sooner had it been embraced by more than half of the practices across the country than it became politically unpopular over concerns of a two-tier service, and it was quickly abolished by the incoming Labour government in 1998.  By this point some practices had become heavily invested in the scheme and its removal represented something of a kick in the teeth.

The Blair government replaced GP fundholding with primary care groups (PCGs).  Here groups of practices were to work together to provide the universal coverage that fundholding had not, with the idea of an indicative budget at each practice level.  However, by 2001 these PCGs were deemed too small and it was announced they were to be replaced by a smaller number of larger more powerful Primary Care Trusts (PCTs), who it was hoped would have more purchasing power.

Of course this meant practices were once again removed from any actual commissioning decisions, and so practice based commissioning was introduced in 2005.  This quickly came beset by implementation challenges, and was ultimately itself replaced (having never really taken off) by Clinical Commissioning Groups (CCGs) when the now infamous Health and Social Care Act was published in 2012.

The death knell for CCGs was sounded in 2016 when Sustainability and Transformation Plans were introduced, as the NHS started on its journey towards integration.  Even though they limped on until the latest Health and Social Care Act had been passed in 2022 they had already effectively been replaced by Integrated Care Boards.

It is not surprising, then, that against such a backdrop of continuous change that many practices are sceptical about Primary Care Networks (PCNs) and their chance of any long or even medium term sustainability.  PCNs were introduced as part of the 5 year GP contract in 2019, immediately after the publication of the NHS Long Term Plan in January of that year, and face an uncertain future as that particular contract draws to an end.

However, when it comes to PCNs there are some important differences.  One is that all the previous incarnations were attempts to place primary care at the centre of the purchasing arm of the internal market model.  PCNs, in contrast, are the first attempt to enable general practice to integrate with the wider system, in this new way of NHS working.

While there were always arguments about the scale required for effective commissioning, there is less debate about the scale needed for integration.  All seem to agree that integration has to start at the local neighbourhood level, and even if you consider Labour’s current shadow health policy they are promoting a ‘neighbourhood health service’.  The pseudo-primary care policy that is the Fuller Report recommends integrated ‘neighbourhood’ teams.

The concerns with PCNs seems to be less about their scale and more about the extent to which they have enabled wider integration.  The debate is also as much about the independent contractor status of general practice (something that never really featured during the purchaser provider era) as it is about PCNs, as this status is regarded as a blocker to integration.

Here is where we get into the real difference of the current situation.  Previously the changes were nothing to do with the core delivery of general practice, but attempts to harness practices as commissioners.  Now the changes are attempts to join up core general practice with the rest of the NHS.  It is not scale that policy makers want to change (the size of PCNs seem about right to them), but the function of general practice behind that scale.

This is important because while for the past 20 or so years a strategy of ‘watch and wait for the latest fad to pass’ has been largely successful, there are warning signs now that such a strategy for individual practices could result in some very unwelcome changes at practice level.

12
jul
1

The Missed Opportunity of PCNs

Posted by Blogs, The General Practice Blog1 Comment

The requirements imposed on practices by PCNs can feel cumbersome and unmanageable.  It is already difficult for practices to cope with all the demands of the core contract, without having the extra demands of the PCN to contend with.  But is there an opportunity in PCNs that many practices are missing?

Most practices have grappled with the question of what is the right size for the practice.  The average practice list size now stands at over 8,500 patients, and there are about 6,500 GP practices.  Over time, the list size is getting larger and the total number of practices is falling.  The financial, workforce and workload challenges faced by individual practices pushes them to need to operate in bigger units to ensure a critical size of workforce is in place and to manage costs effectively.

As a result, many practices consider merger.  Mergers (in theory) allow a larger, more flexible workforce, a stronger and more resilient leadership team, and the opportunity to create back office economies of scale as well as efficiencies in how services are delivered.

But the reality with mergers is that simply merging on its own does not create these benefits.  Delivery of these benefits requires considerable hard work beyond the challenge of merging in the first place.  Indeed, there are many merged practices where not only have none of these benefits been realised, but there is now also an additional tension (and sometimes open hostility) between the two sides that merged which makes the day to day experience of working much more unpleasant than it was previously.

As a result there are many practices with list sizes of well under 10,000 that will not countenance the idea of merger, and will (rightly) point to the strong, cohesive culture they have in their practice and the fantastic results this generates both in experience and outcomes for their patients.

The question, then, is whether there is another way for practices to experience the benefits of operating at greater scale, without having to take the often irreversible step of merging?

This is where PCNs (potentially!) come in.  Could we consider PCNs not as a contractually-imposed burden that redirects both time and resources away from the core contract, but rather as an opportunity to work at-scale with our surrounding practices and explore how the benefits of joint working can be realised free from the legal tethers of merger while at the same time maintaining our individual practice identities?

Prior to PCNs there was no such option available.  But PCNs have a leadership resource, an additional staffing budget, and additional income generating opportunities all in one place.  The PCN construct allows practices to work together and share the potential benefits within a light touch governance framework, and with (crucially) the ability for each practice to maintain its own practice culture and way of working.

The opportunity existing does not mean it is easy to take (as evidenced by the lived experience of many PCNs across the country).  The need to develop trust and build a willingness to cede individual decision making on certain issues is required for a merger to succeed, and this is equally the case in PCNs.  The investment in relationships that successful mergers require is not negated by the maintenance of practice boundaries within a PCN.  PCNs increase in effectiveness as the level of trust grows.

The environment that GP practices are in is tough and it is not going to become more supportive of individual practices any time soon.  There is still at least 9 months of PCNs to go, and most likely another 12 months on top of that, and so now may be the last chance for practices to start working together to make the most of the opportunity that these unique constructs present.

5
jul
0

What does the NHS Workforce Plan Mean for General Practice

Posted by Blogs, The General Practice BlogNo Comments

The NHS Long Term Workforce Plan was finally published last week.  It came in at a meaty 151 pages, but what does it mean for general practice?

Well as with most NHS documents, there is a lot of talk and sell and so it is not easy to get underneath what is actually written.  Equally, it is important to consider what is not being said as well as what is in the document.  But despite all that there are some important takeaways for general practice, as well as clues as to what is planned for the future.

There is no mention of the previously promised 5,000 (which became 6,000) additional GPs.  However, the current problem is at least acknowledged, “the model assumes some boost in GP numbers as a result of interventions in recent years, but the projected growth over the long term fails to keep up with expected demand. In 2022/23 the overall FTE GP workforce (including GPs in training) grew by 1.4%; however, there were 512 (1.8%) fewer FTE fully qualified GPs in April 2023 compared to April 2022. The shortfall in fully qualified GPs is projected to be around 15,000 by 2036/37 without intervention” p35.

The plan to close this gap appears to be threefold.  First to train more GPs:

“To meet the demand for GPs, this Plan outlines a need to increase the number of GP specialty training places by 45–60% by 2033/34. Our ambition is to increase the number of places by 50% to 6,000 by 2031/32. In 2018 the government expanded the number of medical school places by 1,500 and the first of these graduates are now starting to join the workforce. This Plan commits to initially growing GP specialty training by 500 places in 2025/26, timed so that more of these newly qualifying doctors can train in primary care. Further expansion of GP specialty training places will then take place with 1,000 additional places (5,000 in total) in 2027/28 and 2028/29. This will offer the same opportunity to a bigger pool of doctors graduating as a result of the increase in undergraduate places outlined in this Plan.” p41

Second, the use of more specialty and associate specialist (SAS) doctors, with a modelled increase “particularly targeted” towards general practice.  Third, to continue the introduction of new roles into general practice.  The document contains this very interesting paragraph about the ARRS:

“In general practice, we will seek to extend the success of the Additional Roles Reimbursement Scheme (ARRS), which has delivered an additional 29,000 multiprofessional roles in primary care. This would build extra capacity and free up available appointments by increasing the number of non-GP direct patient care staff by around 15,000 and primary care nurses by more than 5,000 by 2036/37.” p95

Extending the success of the scheme is not quite the same as extending the scheme, but it does point to there being some continued growth of funds for additional roles into the future (albeit at a much slower rate, introducing approximately half as many new staff again over an extended 13 year time period).

This also appears to be separate from a further increase in “personalised care roles”, with this expansion quantified as follows (p98):

  • Care co-ordinators: Increase from over 4,000 current posts (September 2022) to 12,000 by 2036/37
  • Health and wellbeing coaches: Increase from over 1,000 current posts (September 2022) to 6,000 by 2036/37
  • Social prescribing link workers: Increase from over 3,000 current posts (September 2022) to 9,000 by 2036/37
  • Peer support workers (mental health services) 4,730 staff in post by the end of 2023/24. Extend growth so there are over 6,500 by 2036/37 (NHS Mental Health Implementation Plan)

Whether or not this is the same thing being reported twice is unclear, but the promised increases do not match up so they could well be separate.  It may also point to a future separation of these personalised care roles from the other roles within the ARRS.

We also get a hint in the document that plans are being developed behind the scenes to bring general practice and the delivery of community services much closer together.  It states, “ICSs will be encouraged to work with partners to support the recommendations of the Fuller Stocktake for innovative employment models and adoption of NHS terms and conditions in primary care” p62.  This does have the feel of wanting general practice to come under the wider NHS umbrella, which would suggest a move away from the independent contractor model (although our current understanding of this is that it will be an option as opposed to mandatory).

It also talks about bringing primary and community care workforce development together, “In 2023/24, NHS England will work with partners to develop a national, multiprofession, integrated community and primary care core capability and career framework to support workforce development” p67.  Whether this is to be applied via PCNs, integrated neighbourhood teams, or some other form remains to be seen.

What appears to be most lacking from the document is any concrete plan to deal with the retention of staff that has proved the biggest challenge in general practice in recent years.  Despite the widespread strike action by NHS staff there is no commitment to improve pay.  There is no recognition that much of the cultural problems in the NHS come from the top and how performance management and regulation are implemented.  Instead, when it comes to retention, the document is full of platitudes like,

“However, there is much more to do to make progress through systematic improvements to recruitment and promotion practices, leadership diversity, disciplinary processes, governance and accountability, and training and education. The NHS must embed a compassionate culture built on civility, respect and equal opportunity” p60

Overall, the document does consistently recognise the increasing role that general practice will have to play in the NHS in future, and has some welcome plans to increase training and capacity.  But as we have seen over the last few years increasing the numbers coming in only helps if we can reduce the numbers leaving, and there is precious little to suggest that this will be changing any time soon.

28
jun
0

PCNs are not the Enemy

Posted by Blogs, The General Practice BlogNo Comments

There is a lot of hate for PCNs at the moment.  Not least the BMA which has just produced its “call to action for general practice” (essentially its wish list for the new contract) and in which it says, “Because it has proven to be a failed project that results in a postcode lottery for patients and patchy staff recruitment for providers, abolish the PCN DES and move all funding and resources into core GMS”.

This is pretty harsh, not least for the thousands of GPs who have worked over the last 5 years in Clinical Director or leadership roles to make PCNs a success.  And (whatever the BMA says) PCNs have not been all bad.  The problem has been an underinvestment in core general practice, not anything that PCNs have or have not done.

The struggles of general practice pre-date PCNs.  Back in 2016, as many of you will recall, the government of the day produced the GP Forward View, which sought to address the challenges general practice was facing.  At the same time I reviewed the options available to practices to create a sustainable future.  Long story short, the main things practices could do was work at scale, introduce new roles, and build partnerships with other organisations in the health care system.

The interesting thing about PCNs is that they provide the opportunity for practices to do each of these things.  They create an infrastructure for practices to work together and achieve the benefits of scale without having to merge, they provide a (fully funded) route into introducing new roles, and they enable a wider set of supportive partnerships with other healthcare organisations to be built that would be much more difficult at the level of the individual practice.

So while I understand the challenges of practices with different cultures working together, and the frustration that all the investment for general practice not coming directly causes, that does not mean that PCNs are all bad, or that there are not opportunities for core general practice within them.

Right now there is precious little support available for practices.  A new contractual requirement has been imposed to respond to patient contacts to the practice on the same day.  Whilst maybe we shouldn’t expect support from the government or NHS England, they simply announced the change on the day it was made driving a slew of calls to practices from patients demanding their “right” to be seen that day be upheld.

The BMA’s response has been to push their safe working guide for general practice.  This is essentially a call for practices to do the contractual equivalent of work to rule as a response to the imposition of the contract changes.  It includes limits such as a maximum of 25 patient contacts per day and 15 minute appointments, with the unmet demand being either referred to 111, A&E or placed on a waiting list.  For many practices deprioritising the needs of their patients in this way is not something they are prepared to do.

The relatively newly formed Integrated Care Boards remain in flux and the majority are able to provide precious little support to practices.  They push the access agenda locally but when it comes to offering tangible support very little has been forthcoming.

All of which (somewhat ironically) means that for most practices right now the major and most fruitful source of practical support is their own PCN.  The best source of support for general practice is general practice, and PCNs provide a simple (and resourced) framework that enables this.  Across PCNs practices can share learning, experiences, ways of working and even, through the ever increasing ARRS teams, staff.  They can access resources to make changes.  They can build shared infrastructure where it can make a difference to local practice delivery.  They can free up leadership time to provide support where it is most needed.

At a time when general practice is under such significant pressure it is not helpful for the service to turn on itself.  PCNs are not the enemy of general practice.  The partnership model seems unlikely to be able to continue on its own, and if PCNs are not in place to support it then the alternatives look a whole lot worse.

21
jun
0

How likely is it that PCNs will go?

Posted by Blogs, The General Practice BlogNo Comments

Many PCNs are finding themselves increasingly hamstrung by the lack of certainty as to what is coming next.  We know the 5 years of the PCN DES comes to an end in March next year, and so the question that many have is whether it is worth investing time and effort into the PCN given the chance that things may all change again in a little over 9 months’ time.

Life for PCN Clinical Directors, managers and leaders is difficult enough, without having this additional uncertainty to contend with.  But how real is this uncertainty, and how likely is it that PCNs will be replaced by something new in just a few months’ time?

The first place to start is the wider NHS environment.  The NHS has entered the new world of Integrated Care Systems (ICSs).  It is fair to say that even those working in these new bodies are finding it hard to fully get their heads round what they are supposed to be doing, but the government’s response to the Hewitt report on ICSs suggests that they are going to remain the overall direction of travel for the NHS into the foreseeable future.

ICSs are premised on all of the different parts of the NHS system working together in partnership to improve the delivery of care for patients. General practice is one of these system parts.  Historically the system has found it impossible to partner with the 7000+ GP practices across the country, which was the main driver behind the introduction of what is now 1250 PCNs around neighbourhood areas.

Given the ongoing push for partnership working across the NHS, it therefore seems highly unlikely that there will be a rowing back from the joint working between practices that PCNs have created.  While this will undoubtedly be much to the disappointment of the many GPs and practices who dislike the requirement to work with other practices through PCNs, this unpopularity will not result in a national reversion to practices as the primary unit for the delivery of resources into general practice.

Instead what we will most likely see is a move to strengthen the joint working between practices across neighbourhood areas that has been developed over the last 5 years by PCNs.

The question is whether this will remain as PCNs per se, or whether these will be changed into something else.  The biggest clue we have as to that question is in the Fuller Report, which states that PCNs are to “evolve into” integrated neighbourhood teams.  It describes these in this way,

“This is usually most powerful in neighbourhoods of 30-50,000, where teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities.” Fuller report p6.

The Fuller report was published over a year ago, and yet still now no one seems any the wiser as to what an integrated neighbourhood team actually is.  While many ICSs have groups looking at this, the timescale set in the report that these integrated neighbourhood teams would up and running in the “Core20PLUS5 most deprived areas by April 2023” has clearly been missed.

The key question appears to be whether an integrated neighbourhood team replaces the PCN, i.e. once there is an integrated neighbourhood team there is no longer a PCN, or whether the PCN represents the group of GP practices that are participating as a group in the local integrated neighbourhood team, which has a much wider group of participants than the PCN.  This latter option appears to be the one being adopted by those places that do claim already to have integrated neighbourhood teams (e.g. Suffolk).

So it would seem that the most likely outcome is that PCNs remain.  Even Labour’s health policy, despite all the noise they have made around nationalising general practice, is to create a “Neighbourhood Health Service”, which very much looks like it has PCNs at the centre.  In fact, given the current policy environment, it is hard right now to envision a future in which there is not something PCN-shaped that continues to be the conduit for the majority of additional resources coming into general practice.

While none of us know for sure what the future holds, it does seem a safe bet that NHS England and the government will want to build on the progress they have made through PCNs beyond March 2024.  There is a chance that the name will change (it is still the NHS after all), but it seem extremely unlikely that the scale of working will alter as there have been no pointers in any other direction.  The pressure for the PCN unit to build more effective partnerships with system partners will undoubtedly grow, but the core unit of the group of practices as a PCN seems destined to remain.

Given this, the most sensible course for practices right now is to continue to invest in the PCN, and ensure that the collection of practices that form the PCN are as solid and secure as possible so that they are as ready as they can be for whatever the evolution is that they will have to collectively face next year.

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