Will the PCN Voice really count?

The Long Term Plan published in January of this year said, “Every integrated care system will have… full engagement with primary care, including through a named accountable Clinical Director of each primary care network.” (1.52)

The GP Partnership Review, published shortly afterwards, said, “Working at scale, for example through Primary Care Networks, has the potential to improve and support general practice influence at a system level.” (p35)

The question is will the establishment of PCNs and the new Clinical Directors really mean that general practice has a voice, and be able to influence outcomes (and the flow of resources) at a system level?  You could argue the establishment of Clinical Commissioning Groups as statutory bodies was supposed to achieve just that, yet they have presided over one of the worst periods of under investment into general practice in NHS history.  Clearly setting up an infrastructure doesn’t of itself necessarily translate into a bigger voice.

Of course, some might argue, CCGs were commissioning organisations and PCNs are provider organisations, so this time it is different.  It is hard for the average GP not to be cynical about yet another promise that “this time it is different”, after so many previous identical promises failed to deliver.

We are heading in the direction of c1000 Primary Care Networks (PCNs) across England.  There are 44 STPs, so we are looking at c20 PCN Clinical Directors per STP.  Even though this is hugely more manageable for system leaders than 7,000 GP practices (c150 per STP), it is difficult to overestimate the challenge for each one of those 20 Clinical Directors trying to influence for their particular PCN.

In the model of “place-based care” (NHS-talk for providers from across health and social care working together at a PCN level), you could argue PCN Clinical Directors will be leading and shaping the integration of services locally.  However, this also depends on whether the reality of how place-based care works is bottom-up (decisions made by local teams), or top down (decisions made at STP level, and PCN leaders asked to implement them).  This in turn will depend on how influential the PCN leaders are at STP level.

The challenge facing the new Clinical Directors of PCNs is formidable.  They have to introduce joint working across GP practices that have never really worked together previously, and manage all the inevitable internal disputes and conflicts that will arise, before they can even start thinking about how they will work with local partners, and how they will create a strong voice for local general practice.

My sense, however, is that it is important to start as you mean to go on.  While the odds may initially be stacked against PCN Clinical Directors, the reality is the system needs them more than they need the system.  There is the opportunity to influence, but only if it is seized and taken from the start.  It is not going to come on a plate, and the new leaders of primary care will need to work hard to establish their voice.  Done badly, the voice will not be strong.  But done well, I think there are many gains to be had for PCNs, their practices, and their local populations.

It is with this in mind that here at Ockham Healthcare we have created a brand new (free) guide for PCN CDs on how to establish an effective voice.  It includes 10 practical steps PCN leaders can take to make their voice effective.  If you are already on Ockham Healthcare subscriber you will receive the guide free via our weekly newsletter on the 9th May.  If you are not a subscriber just sign up here (for free) and we will email you a copy.  I hope you find it useful, and good luck with finding your voice.

Guest Blog – The new Primary Care Network Agreement

This week our old friend John Tacchi returns with a guest blog on the newly published Primary Care Network agreement. A vital set of documents which will dictate the shape of PCNs for years to come.  John critiques the agreement…and doesn’t pull his punches.

NHS England has released the mandatory Network Agreement which all PCNs will have to sign. It consists of two documents, the agreement and the schedules. Given the importance of this document (bear in mind that in future, payments to GPs will increasingly be made to PCNs and less to individual practices), it is a bit thin. Terribly thin in fact. Rather than pick it apart, let us instead consider what it actually says and what is left in the hands of GPs to sort out for themselves.

The Agreement

This is the document that all members of the PCN must sign. It is categorically stated as ‘legally binding’ and so will govern the future relationship of the practices which make up the PCN and govern the flow of money. There are 106 clauses and you would be forgiven for thinking that this is where the ‘meat’ is. These cover general obligations and patient involvement, financial arrangements, workforce, information sharing and confidentiality, conflicts of interest, meeting format (governance generally), joining and leaving the PCN, duration and variation, termination, dispute resolution and ‘events outside our control’.

Except they don’t. The clauses in the agreement all refer to the schedules for greater detail. The schedules document is, however, a series of blanks, leaving PCN members to fill in as necessary. This is not particularly helpful and leaves GPs to sort out a host of vital issues themselves. The top 5 are:

Financial arrangements

There are so many issues under this heading. If one practice in the PCN is designated to receive PCN payments, how will it pay what is owing to other practices? When? On what basis (i.e. what happens if another practice does not provide the PCN services required)? How will be accounted for? What happens when there are other organisations other than practices involved? What about possible insolvency of a practice; how will this impact the PCN? What about intellectual property rights of individual practices/partnerships? How will these be protected? Can individual partners of member practices be sued for the liabilities of the PCN? No detail. Not good.

Workforce

Given the fact that money is being made available for additional roles (but not at 100% reimbursement), who will employ them? If the practice that is the designated fund-holder does, is it aware of the implications from an HR perspective? If another organisation employs them (i.e. a new company), there may be VAT issues. This has the potential to create horrendous problems.

Governance

How will the PCN decide on pressing issues? It will need to have some a ‘board’ of some kind and who will be on it? What will the role of Clinical Director be? Will representatives of the ‘board’ have authority to bind individual partnerships? What is the legal status of decisions made? What about liability issues? How will a PCN vary the agreement if it needs to? Many, many open questions.

Joining and leaving the PCN

This is probably the most glaring ‘omission’ (given the schedule simply says ‘fill in the blanks’). How do practices leave and are they even able to do so? Can a PCN expel a member practice? If so, how? If a PCN expels a practice, what becomes of the patient list? How will they still receive PCN services?

Dispute resolution

What happens if things go wrong? What is the legal status of member practices within the PCN? Who will act as arbiter in the event of a dispute?

Timing is obviously an issue. The network agreement and all its schedules must be signed by all member practices by June 30th.  This is not very far away! The current version does at least say that the agreement can be varied from time to time, but this first draft is so devoid of detail that PCN members really must get specialist advice before signing anything. Lawyers are expensive and it is only the national firms that have the breadth of experience to give a detailed view. They are very expensive. GP’s need specialist advice on this vital issue. And fast!

John Tacchi

Tanza Partners

www.tanza.co.uk

Federations vs Primary Care Networks

There is a tension developing in some quarters between the existing GP federation and the emerging Primary Care Networks (PCNs).  It is like they are trying to compete for the same ground (at-scale general practice), and the result is a growing discord between the two.

A conversation develops about what the federation “offer” is for the new PCNs: will it be for all of the £1.50 per patient running cost, or just a proportion of it?  And what do the PCNs actually get in return for this investment of their money?  Federations can feel they have to justify their offerings, and PCNs can feel they might not be getting value for their investment.

What about the existing work of the federation?  Much of it, such as the delivery of extended access, is funded through monies that in future will be coming through the PCNs.  Will this work continue in its current form, or will the new PCNs demand a different model of delivery to that insisted on by the commissioners?  If it changes, will the GP federation even have a future?

It is easy to understand why tension between the two develops.

For me, however, this tension misses both the point and the opportunity of general practice operating at scale.  Inherent to both PCNs and GP federations is a membership of GP practices (generally the same GP practices).  The point of working together (whether because they choose to or “have to” because of the new GP contract) is to be able to better serve these member practices and their populations.  This is true for both PCNs and GP federations.   The practices are the underlying constant.

So the best place to start the conversation between federations and PCNs is not who should be doing what, and how much they are going to be paid for it, but one between the member practices as to what the relationship between the two is going to be.  The conversation should really be between the practices themselves, working out what they want to do together at PCN level, and what at federation level, and then to organise themselves accordingly.

For me, the most logical step is for the new clinical directors of PCNs to either become the Board, or at least have a majority on the Board, of the GP federation.  This removes the unhelpful sense of competition between the PCNs and federation, and instead enables the PCNs (as the group closest to practices and that hold the majority of the funding) to ensure the federation delivers exactly what the PCNs need.

There is no reason why existing GP federation directors can’t stand and become clinical directors of the new PCNs.  I was asked recently as to whether this would be a conflict of interest.  This question only makes sense if your starting viewpoint is one of competition rather than collaboration between federations and networks.  If the role of the federation is to serve the networks, not only is it not a conflict of interest but it is a pragmatic response to the emergence of PCNs.

For areas that have a GP federation the opportunity exists to have the best of both worlds – scale where it is needed, and a focus on individual local needs.  A GP federation and PCNs working in harmony can secure more investment and resources, create efficiencies by reducing duplication, establish robust and tailored mechanisms for service delivery, limit liabilities, improve patient outcomes, and strengthen the collective voice of general practice.  But whether practices can take this opportunity may depend on their ability to ensure the conversation is focussed on how to deliver the most benefit to practices, rather than one that is competitive between the two.

Primary Care Networks: Learning from the Past

“What has been will be again, what has been done will be done again.  There is nothing new under the sun” Ecclesiastes 1:9.

Primary Care Networks (PCNs) may be the shiny new toy of today, but of course they are not completely new.  At their heart they are about practices working together, about the introduction of new roles, about securing a vibrant future for general practice, about joining general practice more closely together with the rest of the NHS, and about making a difference to local populations.  These are challenges GP practices have been grappling with for a number of years now.

In 2016 at Ockham Healthcare we started the General Practice podcast, and have featured case study after case study of GPs, practices and groups of practices who have been innovating and finding new ways of working to tackle these challenges.

We also published, “The Future of General Practice. Real Life Case Studies of Innovation and New Ways of Working”, in which we highlighted 16 of these case studies, analysed why they had been successful, and distilled the lessons that could be learnt from them. What strikes me now is that this learning is more relevant than ever, to accelerate the progress and impact PCNs are able to make, and to avoid the mistakes of the past being repeated.

The case studies include a focus on introducing new roles.  We considered the impact of pharmacists, first contact physiotherapists, and paramedics, and how they could reduce the workload of GPs.  Even more interestingly, we looked at the development of multidisciplinary teams in general practice, and in particular how in some places they have transformed the management of on the day demand and the whole experience of being a duty doctor in a practice.  Key lessons included starting with the person not the profession, keeping a focus on building a wider team not on individual roles in isolation, and the need to stage appointments of staff over time.

Just like new roles, working with other practices is not new.  There are many experiences out there of what to do and what not to do that those involved in setting up the new PCNs would be wise to pay heed to.  We looked at case studies of mergers over a time period, multiple mergers at the same time, as well as the establishment of a super-partnership.  A whole range of benefits of at-scale working were realised, such as improved resilience, a better ability to manage demand, and greater profitability.  However, we also found simply working at scale does not automatically generate these benefits, and highlighted some important lessons for practices working together to make these a reality.

A key focus of PCNs will be partnering with other organisations, but again this is not completely new ground for general practice.  In the book we considered case studies of practices working with a hospital, with a community trust, with community pharmacy, with the voluntary sector and the local community.  We looked at the benefits general practice was able to achieve through this, such as access to staff, back office support, financial gains, and also what factors seemed to make these particular relationships successful compared to areas where relationships are poor.

There are now less than 75 copies of “The Future of General Practice” left.  To help those who want to learn the lessons from the past as they create the future with PCNs, we are making them available for only £9.99, a discount of over 60%, for as long as stocks last.  Click here for your copy.  The fastest way to success is always to learn first from those who have gone before you.

What is new in the network DES specification and guidance?

Last Friday (29th March) the new Network Contract DES was published.  Six documents in all, and well over a 100 pages of weekend reading (my life is basically one big party).  Much of it restated what we already knew, but I will focus here on the important new things it contained.

There are a number of key changes to the submission requirements.  There has been some talk about the sizes of networks since the new GP contract was published, and how fixed the 30-50,000 population is.  More flexibility is now permitted for the upper end of the range, and where commissioners do agree to larger network sizes, “the PCN may be required to organise itself operationally into smaller neighbourhood teams that cover population sizes between 30 and 50,000”.  There can also be changes to network memberships after the 1st July, but these will require 28 days’ notice, approval from the commissioner, and will only start the quarter after approval is received.

The network agreement now does not have to be submitted by the May 15th deadline, but by the end of June.  Interestingly, it is in a mandatory form (one of the six documents published is the “Mandatory Network Agreement”), a theme reinforced by lines like “we agree that the wording in the clauses to this agreement may not be varied unless a national variation is published”.  There are, however, seven schedules at the end which do allow some variation, and, frankly, seem to me to mean that most networks will need the extended deadline to agree them.  For those interested in hypothetical future scenarios the agreement also includes quite a bit on (amongst other things) the process for leaving/joining networks, expulsion from, dissolution of, and dispute resolution.

More clarity is also provided on who can and cannot be the accountable clinical director.  It can be a clinician (i.e. not just a GP), but they have to be practising within the network area (no out of area leaders allowed).  Four options are suggested for the selection process: election, mutual agreement, selection, and rotation within a fixed term (the latter presumably the last option for those areas where no one is willing to step forward).

What is also new is networks have to be ready to provide extended hours from July 1st, including having in place “appropriate data sharing arrangements”.  If this is done, and the network agreement is completed and signed, the PCN will be considered “established” (a term eerily reminiscent of “authorised” for those still bearing the CCG set-up scars).  Any delays in becoming established will affect payments, most notably the ability to claim the £1.50 PCN funding that will otherwise be backdated to April 1st.

The new GP contract published at the end of January indicated the money for a network could be paid to a lead practice, a federation, an NHS trust or even a social enterprise.  All mention of that is gone in this guidance, which instead states that the recipient of the funding “must hold a primary medical contract” (i.e. a GMS, PMS or APMS contract), thus at a stroke discounting the majority of federations, NHS trusts or social enterprises.

How, then, federations might feature immediately becomes a less straightforward question.  The answer appears to lie in the recently published BMA Primary Care Network Handbook, which suggests one of the potential operating models for networks is to subcontract the provision of services and employment of staff to a federation.  Subcontracting in this way is allowed by this guidance, as long as it has the consent of the commissioner.  There is some complicated VAT guidance also provided, but my take is that as long as the twin traps of simply providing employment of staff (so falling foul of agency requirements) and of separating out clinical and non-clinical services into separate contracts, are both avoided then subcontracting by the networks to the federation is unlikely to incur VAT.

One of the other questions that has been doing the rounds is whether there is financial benefit in networks being smaller to secure proportionally more resources.  I think this guidance effectively puts that to bed by clarifying that even though each network (regardless of size) will initially receive 100% funding for a link worker and 70% funding for a clinical pharmacist, from April 2020 each network will receive a “single combined maximum sum… based on weighted capitation”.  So any advantage gained in 19/20 will be immediately lost the following year by having less left to spend on new roles the following year.  Indeed, the guidance states, “PCNs will not wish to make short term gains to the detriment of longer term sustainability”.

However, in 2019/20 practices can only use the workforce funding to appoint a link worker and a pharmacist, and cannot use the funding for any other roles.  The only flexibility is if a network either cannot recruit to one other of these posts, or already has a “full complement” of one or the other, at which point networks can substitute between the two roles.  The workforce funding for PCNs also means the clinical pharmacist scheme in general practice is being ended.  This means if practices have applied to the scheme, or even been approved for it but have not appointed a pharmacist, they will not now be eligible to go ahead.

The guidance also introduces the concept of “additionality”.  Essentially a baseline of staff numbers supporting practices across the five roles (clinical pharmacist, link worker, physician associate, extended scope physiotherapist, and paramedic) as of 31st March this year will be taken through a combination of NWRS (national workforce reporting system) and a (mandatory for practices) survey by commissioners during April 2019.  The funding for additional staff will be given as long as networks can show that these staff are “additional” to this baseline number.

There is much in the guidance about the supervision and workload requirements of the new staff.  My worry is the level of restriction in the guidance, coupled with the cost pressure and associated liabilities each new member of staff funded at 70% (or less) of total cost presents, may lead to a much lower uptake in the recruitment of the new staff than those writing the guidance are seemingly predicting.

Overall, as is the tendency of all detailed guidance, whilst it may provide some much needed clarity, enthusiasm for the changes will inevitably be dented by the sheer weight of the new instructions.  While some aspects are helpful, some are clearly not e.g. the change to the hosting arrangement options, and the lack of flexibility around workforce funding.

At the heart of the new GP contract was a desire to create a sustainable future for general practice, and yet what seems to be most lacking in this guidance is any focus on how all of this will benefit core general practice.  The challenge for local leaders will be first to understand this guidance, but then, more importantly, to translate it in a way that can still inspire local GPs and practices to make the most of this new opportunity.

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