29
jan
0

The Shift from Primary to Secondary Care: Threat or Opportunity for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

The shift of activity from secondary to primary care is starting to pick up pace.  Does this represent a threat or an opportunity for general practice?

This government has been clear that it wants to see a shift of activity from hospitals to the community, listing this as one of the three big shifts it is seeking to achieve.  These are intended to form the foundation of the forthcoming 10 year plan for the NHS, but there are early indications of what is to come in the recent Reforming Elective Care for Patients document (which we discussed in a recent podcast here).

This contains the ambition for the number of advice and guidance requests to be increased from 2.4M to 4M, along with more patient initiated follow ups, greater use of the NHS App, and GPs to support patients activating choice of treatment provider.

All of these have workload implications for general practice.  Funding has only been identified for the advice and guidance requests (although even then the £20 per request feels inadequate given the amount of work each request entails), but we await details of the 25/26 GP contract.

It is not just elective care.  A similar plan for reforming urgent and emergency care is due out (a draft has already been leaked to the HSJ), and it is hard to see a scenario in which this does not have further workload implications for general practice.

More is likely to follow once the full 10 year plan is released.

Practices, however, are operating at full capacity.  There is not the workforce or space within practices to cope with the existing work, let alone take on more.  Practices are already undertaking collective action in protest at the underfunding and underinvestment in the service in recent years.  One of the things that has irked the service most has been the unfunded shift of work from hospitals to practices.

The threat that this poses to the existing model of general practice is real.  The government is not going to suddenly reverse its push to shift care from hospitals to the community, and practices cannot magic capacity out of thin air.  Something is going to have to give.

General practice could respond to this threat by scaling up collective action to attempt to make the government reverse its plans to increase the workload on general practice in this way.

But given the government has already announced its intention to invest in general practice beyond the levels it will invest into other sectors, it is hard to see a scenario where choosing to do this ends well for the service.  The government has been insistent on the need for reform to go alongside on additional investment, and clearly has question marks about the current model of general practice.

Instead, are there any opportunities that potentially lie within the shift from secondary to community care for general practice?

The most obvious opportunity lies in the funding.  Even with any uplift that is given, the core GP contract is never going to be funded sufficiently again.  All new money now comes with additional expectations, which means general practice is highly unlikely to ever be able to really thrive again if it is relying solely on this contract.

But funding for the shift of secondary care activity is new.  If general practice can find a way of both working this at a profit and of scaling it sufficiently then it does hold out the promise of a secure new future.

The question, of course, is how can it do this?

Each practice can’t do this on its own.  There is not the physical or workforce capacity.  But by working together or at scale, by accessing the resources that come via the PCN, and by developing an infrastructure beyond that which exists within practices and most PCNs, then the capacity can be put in place.

Historically federations and even PCNs have operated too independently from practices for this type of model to be effective in securing individual practice sustainability.  But if practices can develop a model whereby the at-scale work is a core component of the practice business model, and at the same time the at-scale work can develop to make the most of the coming shift of activity, then there is a scenario where general practice can once again thrive.

The shift of activity from hospitals to the community could end up being the final nail in the coffin for the existing model of general practice.  If the elective reform plan is anything to go by then this could come sooner rather than later.  This threat is real.  But it may also be an opportunity for a brighter future for an evolved model of general practice, where a proper support infrastructure enables practices to make the most of this shift in activity.

15
jan
0

4 Important Questions for PCNs in 2025

Posted by Blogs, The General Practice BlogNo Comments

The new government, the end of the 2019 contract and the push for neighbourhoods means the future and role of PCNs is more up in the air than ever before.  Here are four important questions currently facing PCNs.

  1. How will the 2025/26 GP contract affect PCNs?

PCNs are not hugely popular with many rank and file GPs, understandably so given we have seen huge amounts of contract funding redirected away from practices and into PCNs.  The push from the GPC is for PCN monies to be shifted into the core contract.

However, it does not seem likely that there will be a whole new general practice contract for next year.  Back in 2019 the introduction of PCNs followed extremely rapidly on from the publication of the NHS Long Term Plan which came out in January of that year.  As the 10 year plan is not due out until “Spring” it is hard to envisage any large scale contractual change in 2025/26 following on from it, which means a modified version of what we currently have is most likely.

This in turn means PCNs continuing, although it would not be a surprise for the contract to at least contain some pointers as to what is on the way.

  1. How will the forthcoming 10 Year Plan affect PCNs?

A much bigger (albeit medium term) impact on PCNs is likely to come as a result of the 10 year plan.  We are fully expecting neighbourhoods to feature heavily (given the government’s consistent determination to introduce a neighbourhood health service), and it does seem inevitable that the future of PCNs will be linked in some way to neighbourhoods.

A key question will be the nature of the relationship between PCNs and neighbourhoods, along with the extent to which neighbourhoods might be established as NHS entities and what powers/responsibilities/funding they will be given.

Will PCNs need to become neighbourhood-sized?  What will the role of the ARRS workforce be within neighbourhoods, and will general practice maintain the level of control they have over PCNs they have now?  Whatever the answers, it is hard to see PCNs continuing exactly as they currently are once the new plan is out.

  1. Will all PCNs need to form Primary Care Collaboratives?

The NHS Confederation has written quite a lot about primary care collaboratives.  Rather than a PCN or GP federation they mean by this primary care providers coming together to operate at a system level, often as primary care boards.

At present, some PCNs are part of primary care collaboratives (where they exist) but many are not, largely because no such collaborative is in operation in their area.  As ICBs continue to mature, however, the importance of a voice that can articulate how general practice can contribute to and even lead the integration agenda is only increasing.

A key question for PCNs, then, is if they do not yet have a primary care collaborative in place do they need to be working to establish one?  Or if one exists is it effective, and if not what needs to change?

  1. What can PCNs do now to prepare for what comes next?

Faced with so much uncertainty, making any form of preparation is difficult.  But that is not to say nothing can be done.  It is highly likely that the next phase of PCNs will be much more externally focussed.  As such it makes sense for PCNs to both ensure they have strong internal foundations in place (HR, finances, governance etc), and to be developing effective relationships with the other local providers and teams in their area.

If you are struggling with the uncertainty of how to prepare for what comes next for PCNs then the good news is that help is at hand.  I have teamed up once again with PCN Expert Tara Humphrey, and Dr Hussain Gandhi and Dr Andy Foster from the e-GP learning podblast, and we for the third year in a row are holding a PCN conference.

The purpose of this conference it explicitly to provide insights for those working in or with PCNs on what the future holds for PCNs and practical steps on how best to prepare for it.  It is taking place in Nottingham on the 23rd April – for more information on how to book you place click here.

18
dec
0

A New Opportunity for GP Federations?

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GP federations have not had much luck in recent years.  Many were set up with the Prime Ministers Challenge Fund and set up services to deliver enhanced access, and there was a time when the system seemed to be moving towards working with GP practices at scale via GP federations.  Many ICBs even started commissioning their local enhanced services through federations, and for a while the future looked bright for them.

But things took a turn for the worse when PCNs came along with the new GP contract in 2019.  This meant the unit of at-scale working legitimised by the system suddenly became the PCN.  Whilst PCNs were not NHS statutory bodies their basis in the national contract meant they were a recognised part of the NHS architecture.

Many federations, however, were able to adapt accordingly.  Local PCNs often turned to their federation for support with their infrastructure, in particular hosting the ARRS staff with their ability to offer limited liability, and the role of federations evolved.

However, things took another turn for the worse when responsibility for enhanced access shifted from local commissioners to PCNs.  This happened at the same time as NHS England stopped negotiating the annual contract and instead imposed the terms agreed in 2019 despite record inflation figures, leading to significant financial challenges at practice level.

While enhanced access represented the lifeblood for many federations, PCNs and practices were now forced into thinking about how they might be able to provide this service directly themselves.  Now life is even more difficult for federations, as they have sought to adapt and find a way to add sufficient value to their local practices, PCNs and commissioners to be able to survive.

But a new opportunity for GP federations may be around the corner.  We first got an inkling of this in the Fuller Report of 2022.

This report is over 2 and half years old, but it is only now that we are starting to see a real push for the development of the integrated neighbourhood teams that formed the centrepiece of it.  No doubt this is because of how well it aligns with the new government’s desire for a neighbourhood health service.  The report was clear that these teams will require support from at-scale providers,

“System-level expertise on primary care should go beyond contracting to building relationships and developing capabilities within systems as they build their new teams. We heard throughout the stocktake of the importance of a core set of capabilities to support improvement and transformation, with quality improvement; digital, data and analytics; understanding local communities and user experiences; physical infrastructure; workforce planning and transformation; service design; and the development of the primary care provider landscape coming up most frequently.

These key primary care capabilities need to be in place for all systems, but not all need to be provided in-house – some may be brokered or commissioned from other providers at scale: eg GP federations, acute, community or mental health providers, or commissioning support services.” p30

This idea has since developed.  Local manifestations of integrated neighbourhood teams (e.g. NW London ICB) have started to be accompanied by the notion of an “integrator” function.  This is an entity to provide the kind of infrastructure support envisioned by Fuller, as well as play a key role in enabling the different providers within these teams to work effectively together and become more integrated over time.

This may prove to be a make-or-break moment for GP federations.  If they can take on this role there are potentially huge benefits.  The federation will once again become firmly established in the NHS infrastructure, with a line of funding to secure its future.  For general practice it means the role GPs and their leaders within the new neighbourhood teams will be much greater than it would be if this role lands with another provider.  And for the system it means buy in to the new teams from general practice (arguably the most important contributors) is likely to be much greater than with any alternative arrangement.

But if GP federations miss out it is unclear what role will remain for them.  The support services they provide to PCNs will doubtless ultimately be taken on by the new support provider, which will leave the federations in a very difficult place indeed.

The question is whether the GP Federations that remain can adapt and develop sufficiently to be able to take on this integrator function.  The window of opportunity is now for them to work with their PCNs and practices and prepare and actively work so that they are in a position to take on this role whenever it comes up locally.  It is vital federations get themselves ready as quickly as possible, and do all they can to grasp this opportunity with both hands.

11
dec
0

The PCN Neighbourhood Relationship

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Neighbourhoods are on the way.  Ever since integrated neighbourhood teams formed the centrepiece of the Fuller Report this has been clear, but it is now even more so with the Labour government’s repeated statements about a “Neighbourhood Health Service”.  But what do neighbourhoods mean for PCNs, and what will the relationship between the two look like?

Just to be clear right at the outset, PCNs and neighbourhoods are not the same thing.  Maybe the original intention behind PCNs was for them to evolve into some form of multi-agency community organisation, but the reality of where we are now is that the two are very different.  PCNs are groups of GP practices in a neighbourhood area working together, whereas neighbourhoods comprise all the different local NHS, social care and voluntary organisations.

This means PCNs will be just one element of many within neighbourhoods.  For those concerned (or even hopeful!) that neighbourhoods will mean the end of PCNs I don’t think there is any chance of this.  Neighbourhoods need all the GP practices working together and will not want to return to the situation where each GP practice is operating individually.  PCNs will continue, but the question is what the relationship between the PCN and the neighbourhood will be.

We don’t yet know the detail of the plan for neighbourhoods, and will most likely have to wait until the new NHS 10 year plan is published in the Spring to find this out.  But the all the signs are that they will be actual entities (as opposed to the loose collaboration that is perhaps the best description of practices working together in a PCN).  This means that they will be able to hold budgets and have some degree of organisational infrastructure, beyond that which we currently see with PCNs.

The plan for neighbourhoods is that they will be enablers of effective joint working between the different providers in the local area.  So where a PCN might currently run up against a brick wall if it is trying to form an effective partnership with, say, the local mental health provider, the neighbourhood will be able to unblock any barriers and ensure that in this situation the PCN and the mental health provider can find a way of working together.

The question is what levers the neighbourhoods will have to unblock these barriers.  It could be some form of accountability framework, whereby leaders from all the provider organisations form the neighbourhood leadership team and are accountable there for ensuring their organisation participates effectively in partnership working.

This seems unlikely to be sufficient on its own, as partnership arrangements based on goodwill only ever get you so far.  More likely, then, is that there will be some financial levers.  If the neighbourhood controls access to any neighbourhood funding that is announced as part of the new plan, then it can use this to ensure providers participate in neighbourhood working.

These levers may be even more pronounced for PCNs.  It is not beyond the realms of possibility that PCN funding will shift from being a DES in the national contract to being held by the new local neighbourhood entities.  If this does end up being the case then this will mean the neighbourhood effectively becomes the commissioner of the PCN, with huge implications for the relationship between the two.

Another lever neighbourhoods may have is management, operating at a neighbourhood level across all of the different provider organisations.  While the role of this management will be to enable effective collaboration across the different provider organisations, the style of management employed, in particular how directive it ends up being, will directly impact the neighbourhood PCN relationship.

What is clear is that while it may take one of several forms, the relationship between the PCN and the new neighbourhood will be very important.  While at present the PCN’s accountability is contractual for delivering the PCN DES, it could be that in future the PCN may have a direct line of accountability to the new neighbourhood entity.

What this in turn means is that having as much influence as possible now on how neighbourhoods develop locally should be a priority for PCNs.  Neighbourhoods are likely to develop differently in different places, as the whole ethos is that they reflect local need.  Waiting until the 10 year plan is finally published and more national clarity is provided may be too late, because by then many of the important decisions may already have been taken.

27
nov
0

Building Resilience through Collaboration

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Here is a question to consider: will GP practices be more resilient if they focus internally and on core services only, or if they invest time in collaborating with others?  The implications of the response are significant, but the answer is not as straightforward as it may seem.

The natural response when under pressure is to focus internally.  There is a limited amount of organisational resource, and so by prioritising the use of this internally it maximises the impact it has upon the practice where it is needed.  Ensuring internal operational efficiency and making the most of the available resources by focussing them on the core business are sensible responses in times of pressure.

This is part of the rationale for the collective action across general practice.  The service has been underfunded for the third consecutive year, and so the response to focus only on those things that are funded and deliver only those in order to remain viable moving forward (alongside building pressure for more resources) is logical.

However, resilience can also come from collaboration.  In the first instance this can come from collaboration with other practices in the PCN.  Where practices in a PCN are working to support each other, the benefits can extend far beyond those of access to the shared PCN staff and resources.

I was talking to a PCN recently where a practice shared how their computer system had gone down and a neighbouring practice from within their PCN had stepped in to support them so that they were still able to access their patient records.  This would not have happened pre-PCN.

In the same PCN the practices had recognised the resilience challenges turnover of practice managers causes, and as a result have implemented a practice manager mentoring scheme, whereby any new practice managers entering the PCN are allocated a practice manager mentor from another practice who dedicates time to support them as they get to grips with their new role.

The scale of most practices makes them very vulnerable when events such as IT failures and practice manager departures occur, but they can be much more resilient when collaborating effectively with other local practices.  This does not happen automatically as a result of working within a PCN, but resilience benefits such as these exist when the practices within the PCN collaborate effectively.

The business environment that GP practices operate in is also changing.  Previously the GP contract on its own enabled practices to thrive, but now the world has changed.  We already have huge amounts of GP income tied up in PCNs, and the new government’s focus on neighbourhoods means that even though there may be some shoring up of the core contract it is never going to revert to how it was.  Instead, more and more GP funding is going to be tied up in neighbourhood working, i.e. a scaling up of PCNs to include a much wider range of stakeholders.

This means that future income will be dependent on relationships not just with other practices, but with a wider group of local providers.  Effective collaboration with these providers will be key to both accessing this and making the most of potential future opportunities and funding.

So while an internal focus may bring some short term stability, if it is done at the cost of developing productive external relationships it may ultimately end up being damaging.  Longer term resilience will be much more likely to come from collaboration, because this is where both effective support and future funding opportunities are most likely to lie.

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