The Changing Face of At-Scale General Practice

It is not long ago that at-scale general practice primarily meant the merger of practices into bigger practices, the emergence of super-partnerships and the development of GP federations.  But all that has now changed.

This change has come about because the unit of at-scale general practice has changed.  It is now the Primary Care Network.  The PCN is the unit through which investment is made into general practice, through which delivery is expected, through which the workforce is being developed, and through which general practice will have its voice within integrated care systems.

Historically practices were moving towards at operating at greater scale for three reasons: financial, workforce and influence.  In the last two years since PCNs came into existence it has become abundantly clear the best way for general practice to achieve any of those gains is through PCNs.

As with any change, there are winners and losers.  Those most adversely affected are the large and dispersed super-partnerships, and GP federations.

The large super-partnerships spread out across large geographical areas were built on the establishment of a centralised resource whose cost was prohibitive for small partnerships, but is continually reduced by larger and larger numbers.  These partnerships worked to grow their numbers across the country, and in doing so reduced costs and overall profitability.  But PCNs are based on co-located practices serving specific communities rather than isolated practices joined together by a shared central resource, and so the new PCN environment will not enable this model to thrive.

GP federations were a relatively safe unit of at-scale general practice, that allowed practices to retain their individual identity and ways of working but come together on shared initiatives to secure contracts (such as extended access) and funding (such as for GP Forward View work like care navigation and workflow optimisation).  But with practices now within PCNs, and PCNs receiving any shared initiative funding including extended access, the future for federations as a model for individual practices working together seems very limited indeed.

But the shift of focus of at-scale general practice also creates opportunities.  The biggest opportunity comes for practices working together within a PCN.  The closer those practices can work together, and blur the lines between core practice business and PCN business, potentially to the point of full merger, the greater the opportunity for those practices to use PCNs to stabilise and sustain the core practice model.  If the practices can incorporate the ARRS roles along with the PCN DES requirements into its core business, they have a much greater chance of a sustainable long term future than those that treat all of the PCN investment and work as separate to core business.  We will see this disparity magnified as extended access moves into the jurisdiction of PCNs.

The other main opportunity comes for practices to change the function of their federations.  As I have discussed previously, the limits that PCNs put around at-scale general practice (ongoing and increased individual partner liability, a disparate voice across multiple PCNs within an integrated care system area, a limited ability to support and maximise the value of the new ARRS roles) can all be overcome by PCNs working together within a federation.  While the unit of scale for individual practices is now the PCN, the unit of scale for PCNs could usefully become the federation.

Like it or not PCNs are now established as the primary unit of at-scale general practice. The question for practices to consider is how best to adapt to make the most of the opportunities of this new environment.

Could the Vaccination Programme have been Organised Differently?

Last week I considered whether the impact of the vaccination programme might end up being too much for general practice, as a result of the financial and personal challenges that it has entailed.  One of the questions that this provoked was what would I have done differently given the chance to run the national programme?

Of course no one has the freedom to run the national programme.  Even our national primary care leads are constantly negotiating with (and directed by) their own political and NHS masters.  But even with that in mind the national approach could have been different.

The national approach has been characterised, I think it is fair to say, by control.  It started with the insistence that general practice sites were organised via “PCN groupings”.  Why was that?  Well in part it was because of the logistics of the Pfizer vaccine.  But this was never going to be the only vaccine, and the logistics were always likely to change, but there was never a commitment to work through individual practices.  PCN groupings were to be the delivery unit.

The fact is c1000 PCN groupings are easier to control than over 7000 practice units.  Supply can be controlled, delivery can be controlled, cohorts can be controlled.  While the vaccination service has technically been delivered via an enhanced service contract, in reality it has been managed as an NHS directly delivered service.  The daily requirements to provide information, the strict controls on what is and isn’t allowed, and the regular interventions from above into local sites are all testament to that.

This does feel like a taste of the future.  PCNs will increasingly be the ‘go to’ units of general practice, rather than individual practices themselves.  In part this is because it makes ‘integration’ between general practice and the rest of the NHS easier to achieve (e.g. the arrangements for mental health workers in next year’s ARRS scheme), but in part it is because it puts general practice more within the control of the NHS.

Could things have been done differently?  Or did the overriding requirement for speed and rapid mobilisation mean the approach built around national control taken was the only realistic one available?

I think things could have been done differently.  The approach could have devolved more control to local areas.  Local areas could have been given a clear set of outcomes to achieve within a set timescale and a set amount of funding, and could have been allowed to develop and implement tailored solutions for their local areas.   Each area could have created its own, joined up mix of PCN, practice, and mass vaccination sites (or indeed other types of site), that could have worked together to ensure whole population coverage.

We are in a situation where PCN sites, mass vaccination sites and pharmacy sites feel more like they are competing against each other than working together to achieve whole population coverage.  Separate national implementation teams has led to local confusion rather than a joined up approach. If local areas had been able to design their own mix of service offerings everyone could have understood their respective roles and worked together as a local team.

Local areas could also have tailored their approach according to their own local strengths and weaknesses, and challenges.  Rural areas could have taken different approaches to more densely populated urban areas.  Mass vaccination sites could have been targeted where PCN sites found it more difficult to mobilise.  Most importantly, sites within local areas could have actively supported each other, as different members of the same team.

I know it is easy to criticise, and am cognisant of just how successful the vaccination programme has ultimately been so far.  But we are on the verge of a shift in NHS policy towards integrated care systems.  The danger is that these systems, and PCNs within them, simply become different units through which central NHS exercises top down control.

For integrated care and these new ICS systems to really work they need to be locally owned and led, and freed up from top down imposition.  The concern the national vaccination programme highlights is that local freedom and true integrated working will remain secondary to top down national control.  The cost of that approach is things that do not make sense at a local level as well as an unsustainable level of pressure on individuals.

Will the Vaccination Programme prove to be too much for General Practice?

A GP posted this message on twitter last weekend:

Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (you can find it here)

It is an interesting prediction.  I would say general practice is currently divided into two groups.  There are those sites that have a vaccination model that is working well, has a team that is functioning effectively and are not only delivering the vaccine but also deriving huge satisfaction from doing so.

Sadly this group do not seem to be in the majority.  The second (larger) group are those who are both struggling to make the vaccination model work financially, and personally finding the whole process physically and emotionally exhausting.

The financial challenge noted in the tweet comes for a number of reasons.  The Pfizer vaccine is much more expensive to deliver (because of the need to dilute the vaccine, to put a 15 minute observation period in place for those receiving the vaccine, and to staff clinics at incredibly short notice).  There is no additional payment that takes this into account.

The housebound patients simply cannot be vaccinated within the £12.58 available.  Even if the team delivering the vaccinations can be funded (not possible if a GP carries them out), there is no way of funding all of the additional work required such as carrying out the training, gaining consent, validating the Pinnacle records etc etc.

Then there are all of the unseen costs.  Finding staff to book patients at short notice, even on the day of clinic and while the clinic is still running.  Bringing staff in on a Sunday because of an insistence that all of this week’s vaccines are used this week.  Managing the complaints because of the national control-freakery that is being applied to any messaging.  Communicating with practices and GPs who are not crazy enough to engage with WhatsApp groups that spew hundreds of messages a day, but are the only way of finding out what is going on.

Et cetera, et cetera.

If it does come to pass that, once all of the housebound and elderly are vaccinated and the Oxford AZ vaccine is much more widely available, primary care sites are stepped down for other sites, it will genuinely be one of the most galling financial kicks in the teeth general practice has ever experienced.

However, the personal loss for many of those leading the vaccinations is far greater than any of the financial challenges.  It is hard to overstate how all-consuming leading the vaccination process has become for many.  It is 7 days a week with no respite.  There is the weekly wait to find out what vaccines will be arriving, with painful recent scars reminding these leaders not to book anything until national confirmation is received.  Then there is the mad scramble to staff rotas and find patients for the clinics.  Then there is dealing with the inevitable change or late delivery, and having to absorb all of the local patient and staff unhappiness this creates.

For many vaccination leaders their life is on hold.  On top of the clinic challenges, there come new challenges every week – changes to the second vaccine regime, delivering to care homes, to the housebound, changes to Pinnacle, the emergence of a local mass vaccination centre (etc) – all topped with constant pressure from above to do more, faster, better.

The staff they are leading struggle with the pace, but the leaders have to push forward.  The local practices who are not involved push them from the sides.  It is the leaders who bear the brunt of the blame for national rules that don’t make any sense but can’t be broken, like which cohort can be done when, and why vaccine can’t just be given to local practices to administer themselves.

These leaders are PCN CDs, GP partners, PCN managers, practice managers.  They are our local leaders of general practice.  And if not already then certainly at some point soon they will need a break.  Many will simply not want to return.  They won’t stop until the job is done, but I understand a message that says once we get there enough will be enough.  And what then?  Who will pick up the pieces?  What state will general practice be in?  Will it all have been too much?

The 2021/22 GP Contract

NHS England published a letter on the 21st January, entitled “Supporting General Practice in 2021/22”.  The letter states NHS England and the GPC have agreed that, “too much remains unclear to confirm contractual arrangements for the whole of 2021/22”, and so the letter is intended to provide what certainty they can at this point given the pandemic.

The letter reinforces what we already knew, primarily that the majority of the additional investment into general practice is coming via the PCNs.  This primarily takes the shape of the Additional role Reimbursement Scheme (ARRS), where the total pot has been increased from £430M to £746M.

There are some interesting developments of the ARRS.  The most helpful is that those in London can now offer the same inner or outer London salary weighting as other NHS organisations (although they are still restricted to the same total pot).  Three new roles have been added: paramedics, mental health practitioners, and “advanced practitioners”.

PCNs have been looking forward to the opportunity to employ paramedics from April since it was announced last year that they would be able to do so.  There is a nasty sting in the tail in the guidance however,

Where a PCN employs a paramedic to work in primary care under the Additional Roles Reimbursement Scheme, if the paramedic cannot demonstrate working at Level 7 capability in paramedic areas of practice or equivalent (such as advanced assessment diagnosis and treatment) the PCN must ensure that each paramedic is working as part of a rotational model with an Ambulance Trust” p7.

This theme of other NHS organisations bringing their weight to bear on the introduction of the PCN roles is also reflected in the new mental health practitioners.  Here there are even more complicated arrangements at play,

From April 2021, every PCN will become entitled to a fully embedded FTE mental health practitioner, employed and provided by the PCN’s local provider of community mental health services, as locally agreed. 50% of the funding will be provided from the mental health provider, and 50% by the PCN (reimbursable via the ARRS), with the practitioner wholly deployed to the PCN. This entitlement will increase to 2 WTE in 2022/23 and 3 WTE by 2023/24, subject to a positive review of implementation.” p3.

Can the ARRS funding really be counted as funding for general practice if the funding is to be used for staff that are to be employed by the local community mental health provider?  It is a worrying precedent that has been set against the main source for investment into general practice.  It will be interesting to see how PCNs react to this, how keen they are to take up this offer, and what pressure is brought on them if they decline.

In better news the 4 outstanding PCN DES specifications will not be introduced at the start of 2021/22, with an implementation agreed once (if) the Covid situation scales down.  There is no mention of the existing 3 specifications and how they will be monitored through the year – something which varies considerably across the country.  The transfer of extended access will now take place in April 2022 (a more definite statement than the previous “from” April 2022), with the specification to be published this summer (i.e. September).

The Investment and Impact Fund (IIF) will continue.  The existing indicators of seasonal flu vaccinations, social prescribing referrals and LD health checks will continue (thresholds to be determined), which I assume means the prescribing indicators will not.

Finally QOF will remain broadly the same next year as this year.  A vaccination and immunisation domain will be added, adding £60m from the replaced childhood immunisations DES, there will be no new quality improvement modules but LD and supporting early cancer diagnosis will be repeated from this year, and £24M is being added to strengthen SMI physical health checks.

In summary then, no huge surprises, some minor disappointments, but on the whole a pragmatic approach to keeping the focus on the challenge that is front and centre right now of dealing with the pandemic.

Should we Stop Vaccinating While Others Catch Up?

We are at a difficult stage of the vaccination programme.  Some sites started in December, and have been able to largely complete the vaccination of cohorts 1 and 2 (care home residents, those aged over 80, and frontline health and social care workers).  Others have only just received approval for their local site to begin vaccinating, and are only now able to make a start on these priority cohorts.

The challenge is whether the sites that have completed the initial cohorts should carry on with the next cohort (the over 75s), or whether they should be stopped while other areas catch up?  By the time you read this the next cohorts are likely to have been announced, but at present strict national rules mean any area that has completed cohorts 1 and 2 is experiencing heavy pressure not to make a start on cohort 3.

The Joint Committee on Vaccination and Immunisation (JCVI) is clear that the priority for the vaccination programme is the reduction of Covid-19 mortality and morbidity, and the protection of health and social care staff and systems.  The age based strategy in place has been selected as the best option for preventing morbidity and mortality in the early phase of the programme, because “Current evidence strongly indicates that the single greatest risk of mortality from COVID-19 is increasing age and that the risk increases exponentially with age” (p4).

The strategy is clear.  So if the constraint in the system is the supply of vaccine it makes perfect sense that the supply should now be prioritised to those areas that are catching up and still have over-80s to vaccinate.  It is up to the national team who decide who is receiving supplies to ensure it goes to those sites.

The complexity comes when the constraint is not supply but delivery capacity/capability.  If a site has completed cohorts 1 and 2 and receives a supply what is it to do?  The national mandate is that this site must now help other sites to deliver cohorts 1 and 2.  This is sensible, but there are two problems with this.  One is geography – how practical is it for the over 80s to travel to an area that is further away to receive the vaccine; and the other is logistical – the Pfizer vaccines have to be used within a very short number of days, and so delays in booking patients leads to a much higher risk that the vaccines will be wasted.

Many sites have been scrambling around for patients to ensure that vaccine isn’t wasted at the end of a session.  There are reports that some sites have not been able to use all their vaccine because they have not been able to find people from the right cohort in time.

To an outsider this seems strange – surely no one would let any vaccine be wasted?  But there is heavy system pressure applied to sites about not vaccinating outside of the allowed cohort, even after Pfizer vaccine has arrived on site and the clock has started ticking.  Threats are made that sites supplies will be cut off if they go outside the cohort.  So some vaccine has been wasted.

There needs to be a balance between striving to achieve the strategy of delivering the vaccines in priority order and a pragmatism of applying this goal so that we make the most of the vaccines we have.  The JCVI itself advised that,

Implementation should also involve flexibility in vaccine deployment at a local level with due attention to… vaccine product storage, transport and administration constraints… JCVI appreciates that operational considerations, such as minimising wastage, may require a flexible approach, where decisions are taken in consultation with national or local public health experts.” (p11)

It does not feel like we have got that flexibility in the system right yet.  As ever, the top down nature of the NHS is resulting in local inflexibility when flexibility is required.

If supply is not the constraint and some areas can go faster, and cannot for geographical and logistical reasons help other areas, surely it makes sense to let them vaccinate their local population as quickly as possible (in cohort order)?  Holding back supplies so that we all move at the pace of the slowest does not feel like an appropriate response to the crisis we are all currently in.

This is only the first time we are moving from one cohort to another; there are many more such movements ahead.  General practice has stepped up and is doing an amazing job of mobilising and responding to the call.  The numbers already vaccinated is  a testament to this response.  Let’s not let system bureaucracy impede the incredible effort that is underway.

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