How is our PCN doing?

As we come to the end of the third year of the PCN it is a natural time to review how things have gone so far, and to consider what might need to be different going forward.  But how do we know how our PCN is doing?

I am struck by the number of PCNs that tell me that they are “behind other PCNs”, even when to me they seem to be extremely well.  Sometimes we hear success stories from other PCNs and assume that this is what “everyone” is doing, and that we are somehow falling behind.  But PCNs are not a race or a competition, and it is up to each PCN to determine what success looks like for itself.

I wrote last time about the importance of a PCN vision, and the need for the practices in a PCN to set their own direction to determine what they want from the PCN.  One measure for how well we are doing is the progress we are making against our own priorities for the PCN (which may well be different from those of other PCNs).

But it is not the only measure.  At their core, PCNs are a joint working initiative across the member practices.  Whatever desired outcomes the PCN has set, a key metric for any PCN is the level of trust that exists between the members.  The more we trust each other, the easier working together becomes.  And this is where we get into the importance of the culture of the PCN.

When you ask member practices about the PCN and how well it is doing the response is rarely about whether the PCN is achieving its goals.  Instead the framing of the response is often about how involved they feel in the work of the PCN, its relevance to them, and its impact (positive or negative) upon them.

So while in part the response is about the level of alignment between the PCN’s goals and the practice or individual’s goals (e.g. is it reducing or increasing my workload), it is also about the way the PCN operates.  Do member practices feel involved in decision making?  Do they feel able to shape the activities of the PCN?  Do they know what is going on?

This is essentially what the culture of the PCN is – “the way we do things around here”.  If the culture is strong, is built on a solid and developing foundation of trust, and the member practices are happy with it, then the PCN has a solid foundation to go on and achieve whatever it wants to in the years ahead.  But if there is unhappiness with the culture, complaints about the lack of communication, disengagement from practices, and a general lack of trust, then regardless of what has been achieved so far it is likely to be a difficult road ahead.

Determining how well we are doing in a long term joint working enterprise like a PCN needs to be as much in terms of how we do things as what we have achieved.  If we are taking time out to take stock of where we are as a PCN (and I strongly recommend that you do!), then make sure to spend as much time on how the PCN is working as what you want it to achieve.

Time to Revisit the PCN Vision?

It is always an interesting to hear the response when I ask the leaders of any PCN whether they have a PCN vision.  Most commonly they recall doing some work on this a few years ago when the PCN first set up, but equally could not tell you what it is.  So is it time to revisit the PCN vision?

The problem is most of the work that goes into establishing what the PCN vision should be focusses on the words in the vision itself.  PCNs end up with some form of ‘vision statement’ that acts as the end product to the work, which is often some noble statement about supporting people to have better outcomes and working in partnership (etc).  But what happens to it, other than it ending up on the PCN website or being used as evidence in the latest PCN maturity matrix assessment?

It is not a surprise, then, that members of the PCN cannot remember what the PCN vision is, because its relevance to the members is limited at best.

The point of a vision statement is to establish why you are undertaking the enterprise in the first place.  Why has each practice signed up to the PCN DES?  What do we want out of it?  What problems are we all experiencing that we think the PCN may be able to help with?  If the vision statement can get to the heart of this, it becomes much more powerful.

The simpler the PCN vision is the better.  Compare these two PCN vision statements (these are real, anonymised PCN vision statements):

  • Member practices of XXX PCN will work together to improve access to the local community. Extending the range of services available to them, by helping integrate primary care with wider health and community services. We will work in collaboration with others – health and social care services, the voluntary sector, community groups and local people – to make best use of available resources, creating a seamless approach, whilst making sure that everyone gets the right support, in the right place, at the right time.
  • To create a sustainable future for our practices.

Which is most powerful?  The point of a vision is not that it creates a statement that everyone can sign up to (but ultimately can’t remember), but rather acts as the guiding force behind the decision making within the PCN.  The vision tells us where we are going, and everything else we do should fall in line behind that.

This is why having a clear vision for the PCN is really important.  If we do not have a shared vision across our practices of why we are participating in the PCN in the first place, then we have no clear point of reference for our decision making.  In the absence of our own direction, we let the PCN DES itself dictate our actions.

The PCN DES is produced in a way that enables the general practice leaders that negotiated this additional funding and resources for general practice to justify the investment.  The additional £2bn that it brings has to come with an output, and so those in charge can point to things such as its contribution to the long term plan (the PCN DES specifications) and enabling general practice to work within the integrated care system.

But that does not mean that this has to be how it is used by practices.  While the contractual requirements are there, what practices need to do is work out how they want to make the most of the opportunity that it brings.  Practices can set their own goal or goals, and then the challenge is to work around the contractual requirements to achieve these goals, not simply provide what others want.

If you do not know what your PCN vision is, now is definitely time to take stock and consider what you want it to be.  If you don’t, you are defaulting to a position where others are effectively deciding what you do (because you are simply led by the PCN DES requirements).  Take the time to come up with more than a statement that everyone will agree to. Come up with what you all want to achieve, and that can guide your collective decision making and actions going forward.

Should Practices Opt-Out of the PCN DES?

April will mark one of the few opportunities practices have each year to opt out of the PCN DES. Is this a move GP practices should be considering, or do the benefits of staying outweigh the additional requirements on practices?

The lack of a negotiated contract for this year means the existing 5 year deal for general practice agreed by the GPC in 2019 rolls through into next year.  The response by the GPC has been a thinly veiled encouragement for practices to consider opting out of the PCN DES, “Should practices decide that they cannot accommodate the below changes, that their patients would be better supported outside of the PCN DES, that the practice would operate more effectively and safely outside of the PCN DES or any other reason, they are able to opt-out” (GP Contract Changes, BMA).

This theme is continued in the BMA’s recently published “Safe Working in General Practice”, which states, “There is an increasing view that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS staff… Practices will need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their wider practice, and their present workforce”.

This all feels somewhat disingenuous, and more of an attempt by the BMA to score political points over NHS England than genuinely putting the interests of practices first.

The reality of the 2019 deal and the introduction of the PCN DES is that it put an additional £3 billion funding into general practice, £2 billion via the PCN DES.  The majority of that funding has not yet come through.  We are only half way through the recruitment of the ARRS roles, the IIF funding has been limited due to covid and grows significantly over the next two years, and enhanced access brings £6 per head under the control of PCNs that previously in most places came nowhere near practices.

From a staffing perspective there are no new GPs, and whatever the promises (5,000 GPs, 6,000 GPs etc) there are unlikely to be any anytime soon.  The only way for practices to manage the ever increasing workload is to use different roles.  Notwithstanding the challenges of training, supporting and integrating these roles, they are the only realistic route for practices to find a way of managing the workload.  100% reimbursement (even if that doesn’t mean free) for these roles is not a bad deal.

PCNs are also the only route by which general practice can influence the newly developing integrated care systems.  The future NHS is not interested in any provider that wants to stand alone and not work in partnership with others.  If general practice wants to continue to be able to have a voice post-CCGs then it needs to work on how its PCNs can influence local arrangements.

The alternative is, as the BMA points out, to opt-put of the PCN DES.  This means practices will lose out on the PCN funding, the ARRS staff and worse, “NHS England is likely to transfer the funding, requirements and staff – likely via TUPE (Transfer of Undertakings) – to Trusts or alternative providers to maintain as much of the PCN DES as possible without general practice.” (GP Contract Changes, BMA).  Given the current Secretary of State’s penchant for nationalising general practice I am not sure the government would be that uncomfortable shifting PCN resources to acute trusts and making practices even more vulnerable going forward.

The only real rationale for opting out of the PCN DES is a protest vote because of the lack of any negotiated outcome to this year’s contract, which is what the BMA seems to be pushing for.  But any rational analysis of the situation shows that it is in practices best interests to stay in the DES and to continue to be able to access its (growing) resources.  That said it doesn’t mean things shouldn’t change.  As I have argued previously, in many places PCNs are too distant from practices, and not run with enough attention being paid to the sustainability of practices in mind.  Now is the time not for practices to opt-out of the PCN DES, but rather to ensure that the PCN DES, a part of the national GP contract, is playing its part in ensuring the future sustainability of the service.

Where is the National Leadership of General Practice?

The move into integrated care systems means the importance of GP practices in a local area working together to create a strong and united voice is greater than ever.  It is not easy, but in lots of areas PCNs, federations, LMCs and even CCG GPs are working out how they can set aside their differences in order to increase their influence in the new arrangements.  But why is the same thing not happening nationally?

There is a lot going on nationally around general practice right now.  The contract for 2022/23 has been issued without any agreement between the GPC and NHS England for the first time that many of us can remember.  I don’t think I have ever seen a clearer signal that a unified national GP voice is 1) needed and is 2) absent.

It is not only the contract.  The Secretary of State Sajid Javid clearly has some pretty radical ideas when it comes to general practice.  He happily wrote the foreword for a recent publication by think tank Policy Exchange that advocated for the end of the national GP contract and for practices to be nationalised.

We also have the Health and Social Care Committee chaired by Jeremy Hunt, and its Inquiry into the Future of General Practice.  There must be a danger that general practice is becoming a political football between the former and current Secretary of State, as they seek to score political points off each other.

Within this context the profession needs strong and united leadership.  I don’t mean union style demands for more (money, staff, support, GPs etc), as the landscape clearly requires a more refined political touch right now.  No sector, whether it is hospitals, community trusts or mental health providers, will succeed right now by framing what they need in isolation from the rest of the system.  Instead they need to demonstrate their contribution to the wider system, and how investment in them can play an important role in making the integration agenda a reality.

It is not hard to hear the acute trust voice advocating for themselves as large, functioning organisations to be the ones who should take general practice under their wing to create joined up pathways of care for patients inside and outside hospitals.  What general practice needs is not only leadership that will articulate the obvious fallacies in such a plan, but also be able to put forward compelling alternatives that build the role and influence of the service.

The problem comes in holding the support of frontline practices, many of whom want to hear their leaders demanding more, and at the same time operating within this political national environment.  Too often GP leaders will simply repeat the demand for more (see this response to the Policy Exchange report from the RCGP) in order to curry favour with practices, rather than because it has any chance of influencing anything.

National GP leaders need to start modelling behaviours for local GP leadership.  It would be great to see the GPC, RCGP and the GP leadership team at NHS England working together as a united group.  There are some very talented and capable individuals across these organisations, and they could work together to strengthen the national influence of general practice (which would be in sharp contrast to the void we have now).  Together they could find ways of both having an impact on how integrated care arrangements develop, and at the same time be able to take practices with them.

When the GPs at NHS England and the GPs in the BMA talk against each other, it is the service as a whole that suffers.  It doesn’t matter who is right and who is wrong.  In the present day context general practice needs to be united at every level, and we especially need that at a national level.  Surely now it is time to put organisational differences aside, and to start working together for the service as a whole.

 

Guest Blog : What do the new Enhanced Access Requirements Mean for General Practice?

Access remains a highly contentious issue and the latest publication from NHS England regarding the 2022/23 contract updates has resulted in a wave of concern from some GPs and unhelpful headlines in the usual suspects of newspapers.

Negativity permeates a lot of what we are doing as a professional sector and in many parts of society. It is easy to look at perceived problems and often hard to focus on the positives.

Of the Clinical Directors, PCN Managers and GP partners I have discussed this with, once we spent some time assessing the impact on them and their practices, it has been evident that this change is likely to bring about a number of positive outcomes. I wanted to share this with a wider audience to hopefully improve the perception of the changes.

Is there a greater time commitment?

If you are in a practice that has never delivered the Extended Access requirement and you have limited engagement with Improved Access it may feel like an increased obligation.

In most other cases it will be the same and, in some areas, could be a reduction of time. There are areas who have been working under Improved Access at or close to 45 minutes per 1,000 patients plus the 30 minutes of Extended Access. For these areas the strict obligation will be easier to provide.

Services I am involved with have been operating on a model of 37.5 minutes and in practice we have been delivering closer to 50 minutes under Improved Access at the request of our member practices. Consequently the new combined requirement will be between 7.5 and 20 minutes less than currently provided.

Many other areas are the same, but it is essential to ensure that the time requirement is tracked on a like for like basis.

Is there sufficient funding?

The letter states that NHSE will ‘bring together, under the Network Contract DES, the two funding streams currently supporting extended access to fund a single, combined and nationally consistent access offer…’. This means that for every patient £7.44 will be available.

Currently £6 per head is commissioned by the CCG and is paid to the local provider of Improved Access. Some PCNs took responsibility for this funding and commissioned their own Improved Access in 2020, others received the service indirectly through federations.

By moving this fund into the PCNs it is arguably the first significant funding stream that can significantly improve the performance and structure of the network.

The following table provides a quick reference to the new time obligations and funding to support it:

PCN Size Additional Minutes Additional Hours Funding per Annum Funding per Week
20,000 1,200 20 148,800 2,862
30,000 1,800 30 223,200 4,292
50,000 3,000 50 372,000 7,154
75,000 4,500 75 558,000 10,731
100,000 6,000 100 744,000 14,308

 

It is important to recognise that some of this money is already being used by practices and other funding will be with federations or other third parties. The effect of moving these funds into the PCN need to be carefully considered locally so it does not destabilise other services which may be relying on top slicing these revenue streams.

Will the workload increase?

The guidance is vague and in many ways that is far better than the current requirements managed by CCGs. One of the biggest challenges with Improved Access contracts was the focus on appointments of 15 minutes. This resulted in a limiting factor which either excluded or made it very difficult to count many of the more innovative uses of the additional time.

Group consultations, tissue viability clinics and DVT management clinics were some examples that delivered excellent patient outcomes but struggled to demonstrate the appointment counting criteria.

The new requirement simply states that the time is used for ‘any general practice services’. A narrow interpretation for this could be a full suite of services but I would recommend that unless further guidelines are brought out, we use a broad interpretation. Our focus will be on delivering those general practice services which are making the biggest impact on our patient’s needs and preferences.

In some areas this may be a full range of services in others it could be a focus on cohorts of patients. I am aware of a PCN who focuses on weekend clinics for the elderly as they discovered it was the best time for family and carers to help the patient travel to the practice.

This type of patient focused service modelling is at the heart of the original PCN concept and this is an opportunity to start shaping support around them. This is the first requirement in the preparation stages outlined in the guidance.

Sharing the workload between practices by developing shared services across the PCN should improve the levels of demand on practices if managed correctly.

Will much change?

For many practices probably not. Enhanced Access is not significantly different than the current arrangement and as argued above it provides new opportunities to PCNs in terms of service design, improved funding and integrating workloads.

The option remains for PCNs to take responsibility for the funding but to agree with practices and with other providers to continue providing existing levels of cover and services. As long as these meet the minimum requirements and the parties are happy with this approach this allows continuity whilst giving more financial control to the PCNs.

This may well be the stop-gap position whilst a longer term review and service redesign process is instigated by the practices to shape services in the future.

If you are in an area with poor service availability with current Improved Access providers, this situation should improve as you take greater control. There are also areas where the CCG top-sliced the £6 figure, so in these areas the full amount will be made available to practices for the first time.

There will be exceptions to this principle but in general this is a change which should be seen from a positive, pro-GP perspective.

Next Steps

We have until October before the new requirements go-live and first drafts of the Enhanced Access Plans need to be submitted by 31 July 2022. This time will fly by quickly so it is better to get started at the earliest opportunity.

It is likely that these plans will be subject to a form of localised template but in the meantime PCN teams can look at current arrangements, discuss with the practices how they want to manage the transition from the current service and speak with your current Extended Access providers.

You can also engage with your patients at the earliest opportunity. Use different data sources to build a picture of the changes that are most likely to improve services as a whole.

This information will be a great starting point to manage the transition to the new specification and you may be surprised about how little change is needed. For others this is a chance to start implementing some of those longer-term aspirations you have had and to start those service improvements which have been delayed in recent years due to the pandemic or a lack of funding.

It can be hard at times to be optimistic, but I am convinced from the discussions I have had over the past few days that this is a change that should be embraced rather than feared.

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