18
sep
0

What does the Darzi Report Mean for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

Lord Darzi has carried out his “investigation” into the NHS, and recently published his findings.  It is a meaty tome at a 163 pages, but what does it mean for general practice?

Unlike some other NHS reports, general practice features heavily throughout, and is not added on as an afterthought.  In the summary letter the second issue highlighted (after the NHS not being able to keep its promises) is that people are struggling to see their GP:

“GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level. There are huge and unwarranted variations in the number of patients per GP, and shortages are particularly acute in deprived communities.”(Summary, 6)

This kind of positioning is not going to be followed by a lack of action.

Does this mean more money?  Well, there is a clear recognition that there has been a failure to invest in general practice, “We have underinvested in the community. We have almost 16 per cent fewer fully qualified GPs than other high income countries (OECD 19) relative to our population” (Summary, 13).

However, there are also criticisms of the GP contract, “the current GP standard contracts are complex and can mean that doing the right thing for patients can require doing the wrong thing for GP income. That cannot be right.” (5, 36).  And when it comes to primary care estate, “It is just as urgent to reform the capital framework for primary care as for the rest of the NHS.” (5, 37)

The idea that pervades the report when it comes to general practice is that it needs to be invested in but it also needs to change.  The basis for this change centres around the need for community based multidisciplinary team working.

In chapter 3, on quality of care in the NHS, when discussing long terms conditions it states, “As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace. GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure and authority that this requires.” (3, 32)

Again in Chapter 5, “People with two or more conditions (whose prevalence is growing over 6 per cent) may require care from different specialists and the expertise of GPs and others to understand the interactions between their conditions, treatments, and medicines. Since healthcare is organised around groups of professionals with similar skills (such as GP practices, mental health or community trusts, and hospitals), it requires organisations to work well together.” (5, 8)

The report calls this shift of resources out of hospitals and into the community a “left shift”.  However, the report is clear that such a shift must come alongside a change to the operating model, “Changing both the distribution of resources and the operating model to deliver integrated, preventative care closer to home will be strategic priorities of the NHS in the future because they are derived from the changing needs of the population.” (5, 21)

The report calls much of what has happened so far within integrated care systems as “collaboration”, but not “integration”.  It clarifies the difference between the two, “Collaboration and integration are often conflated, but they are not the same. Service or clinical integration is about a fundamental change in the way health services are organised for patients rather than the degree to which NHS organisations cooperate with one another as institutions.” (5, 23).  The report raises a concern that current collaborations are not effective and states that, “there is a real risk that they amount to displacement activity from the strategic priorities of delivering integrated, preventative care closer to home” (5, 25).

Primary Care Networks, interestingly, receive only one mention in passing in the entire report.  They are certainly not presented as the solution to the need for effective multidisciplinary team working.  So even though PCNs would seem to tailor perfectly with the Labour idea of a neighbourhood NHS, it may be that they are viewed more as “collaboration” than “integration”.

In his conclusions, the themes Darzi pulls out include these:

“Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen.

Simplify and innovate care delivery for a neighbourhood NHS. The best way to work as a team is to work in a team: we need to embrace new multidisciplinary models of care that bring together primary, community and mental health services.” (Conclusion, 6)

These two recommendations sit alongside each other.  So the good news is there will be new investment, but the bad news is that it will almost certainly come with a requirement for a whole new way of working.  What this will look like remains to be seen, but the government has been very keen indeed since the launch of this report to stress that any new investment will be accompanied by a requirement for reform.

11
sep
0

Should Practices Leave the PCN DES?

Posted by Blogs, The General Practice BlogNo Comments

The BMA has published its Safe Working in General Practice Guidance, which is in effect its guide to collective action.  It does not appear to be full of any major surprises, and rather provides practical guidance for practices on how they can implement the changes that they have already described.  However, it includes a section on the PCN DES, which raises the question of whether it would be better for practices to leave the PCN DES altogether.

To be clear, the guidance does not come out and outright say that practices should leave the PCN DES.  Instead it is implied.  It states, “Many feel that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS (Additional Roles Reimbursement Scheme) staff.”  It then states, “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” before going on to outline the mechanism by which practices can choose to opt out.

“Many” is a vague term.  It implies the majority of people, but it can simply mean a large but indefinite number.  If it was true that the majority really thought the requirements of the DES outweighed the benefits the current sign up rate to the PCN DES would not be over 99%.  Many dislike the requirements of the DES, but that is not the same as considering that their practice would be better off financially by not being part of it.

The problem of leaving the PCN DES is not just about losing the resources (both the financial income streams and the ARRS staff).  It would also mean GP practices ceding control of the PCN and these staff.  As the BMA guidance points out, ICSs are obliged to continue to provide PCN services to practice populations, and so the most likely scenario in the event of general practice refusing to take this on is a neighbouring PCN or another provider such as a community or acute trust taking the PCN on.

Strategically, this would be a terrible outcome for local general practice.  While the BMA sees a very clear distinction between investment in core general practice and overall primary care funding (i.e. including PCN funding and other non-core general practice funding), the government do not.  The government has committed to increasing the percentage share of NHS funding that primary care receives, but if general practice loses control of PCN resources it could end up receiving very little if the additional funding comes through that channel.

The BMA don’t believe that another provider would be able to take on the PCN responsibilities if practices withdrew.  But ultimately it is not their livelihoods that they are gambling with if they are wrong.  The BMA wants the funding that goes into PCNs to be shifted to core contracts.  But national policy is firmly against this, and so practices that resign from the DES will be taking a huge personal risk that this is what will happen when the likelihood is that it will not.  There are clearly divisions within general practice as to the value of PCNs, and so there is not going to be a mass resignation from PCNs, meaning those that do leave are going to be very exposed.

At present, practices can work with their PCN to find mutually beneficial ways of ensuring PCN requirements are managed alongside supporting practice sustainability, both through direct financial flows and through PCN services like pharmacists and home visiting teams that support practice work.  But if ties were to be severed, then this link and these opportunities would be lost, and practices in a far worse position than they are now.

NHSE and the government like PCNs, which is why from the BMA perspective resignations from the PCN DES are desirable as a leverage for negotiation.  But the risk to those that take such a step, when the BMA have not come out and explicitly said that this is what they want, is extremely high.  Rather than leaving altogether and losing the opportunity to access the existing and (potentially larger) future resources, it would seem a much more sensible stance for practices to stay within the PCN, keep control, and campaign to be able to access more of the PCN resources in future.

4
sep
0

Are PCN CDs Due a Pay Rise?

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There is a lot of talk at present about pay rises for practice staff and ARRS staff but what about PCN Clinical Directors?  Should PCNs and practices also be considering a pay rise for this important group of staff?

Many PCN Clinical Directors have been in the role for many years, some since the inception of PCNs back in 2019.  While a minority of more progressive PCNs have actively considered the notion of pay progression for their Clinical Director, the majority have not.  In part, this is because prior to this year the funding allocated to the Clinical Director role was always specified in the PCN DES as 72.9p per patient, and so this was the amount paid.  In part, it is because the only people who pay real attention to the incomings and outgoings of the PCN are the Clinical Directors, and it is very difficult for them to suggest a pay rise for themselves.

But while the reimbursement has not changed, the role of the PCN Clinical Director has grown considerably over the last five years.  Many now have overall responsibility for an army of ARRS staff as well as a range of joint service provision such as extended access and vaccination services.  From operating initially as a one-man band many CDs now lead a significant PCN team and have a range of external responsibilities on behalf of the PCN.

It would make sense, then, if the reimbursement for the role kept pace with the growth in responsibility.  Not only that, but retention of PCN CDs is an important issue.  High quality PCN Clinical Directors are in relatively short supply.  Most PCNs do not have a queue of suitably skilled individuals who could just step into the role.   Just because your PCN CD has not mentioned a pay rise does not mean that they are happy without one.  Failure to provide a pay rise may ultimately lead to PCN CDs walking away from the role, primarily because of the lack of recognition that it signals for the work they are doing.

In theory the shift away from a separate Clinical Director payment (£0.729 per patient), PCN leadership and management payment (£0.684 per patient), and core PCN funding payment (£1.50 per patient) into a newly combined core PCN funding payment of £2.916 per patient this year should have provided much more flexibility for PCNs to re-consider the payment for their CD.

However, the reality is that the core funding element of PCN monies has always come under much more scrutiny and control than any other element, as practices are mindful that any amount unspent in this pot can be returned to practices.  As such the purse strings of the new combined pot have in many places become much tighter now than they were previously on the leadership and management payment, making practice agreement to a proposed rise much harder to achieve.

So PCN CDs who are desperate to either recruit or retain their management support will often prioritise uplifts for these staff over themselves (and will often struggle to get those through), and the issue of whether the CD should have a pay rise never even gets consideration.  I am yet to hear of a PCN that has a separate renumeration committee (although I am sure you are out there, but do get in touch if you are and it is working!).

My advice to PCNs, especially those with an effective CD in place that they want to keep in the job just as long as they are willing to do it, is at this time of salary reviews and changes to make sure that the PCN Clinical Director does not get overlooked, and to consider an uplift to their remuneration as a tangible recognition of how the role has developed and grown over the past few years.

24
jul
1

Diseconomies of Scale

Posted by Blogs, The General Practice Blog1 Comment

The NHS mantra that bigger is better and that the best thing for general practice is for it to grow in size is one that mostly goes unchallenged.  Surely it is obvious that if we want to join up care around the needs of the patient then it can’t possibly make sense for there to be 6500 individual practices, as this is far too many for the NHS to sensibly do business with.  But what if the issue is that the NHS is too big, not that general practice is too small?

Most of us are familiar with the concept of ‘economies of scale’.  These are the cost advantages organisations can gain from increasing their size, which come from both spreading the fixed costs such as management, accounts, HR and IT more widely (and so for general practice result in less of the £ per patient received being spent on them), and from reducing the variable costs by enabling a greater skill mix, more specialisation, more investment in IT and lower procurement costs (so that actual cost to the practice per patient can be reduced).

However, it is does not follow that the greater the size the lower the costs.  What happens is that another concept – ‘diseconomies of scale’ – kicks in.  Diseconomies of scale happen when a company grows so large that the costs per unit (in our case per patient) actually increase.

Costs grow with size for a number of reasons.  Practices become too large to be properly coordinated, which in turn creates more work and issues than when everyone knew everything that was happening.  Diseconomies of scale also occur because of the difficulties of managing a larger workforce. Communication is less effective, staff don’t feel listened to and don’t feel part of the organisation, and this in turn affects productivity.

The biggest issue with scale in the NHS is the distance it creates between those delivering front line care and those making decisions about the organisation.  In GP practices the partners for the most part also work on the front line delivering direct patient care.  They understand the challenges, and the decisions they make are intended to resolve them.

Once a practice covers multiple different sites then a distance is created between the challenges at any individual practice and the decision making of those in charge.  When this distance becomes too great, diseconomies of scale can kick in.

Think how hard it is for a PCN CD to manage the needs of each of the member practices and meet the requirements of the PCN DES.  For NHS organisations this issue is magnified.  Not only are the leaders a huge distance from the front line of care delivery (consider the executive offices running a group of NHS hospitals, as is increasingly becoming the NHS norm), the motivation behind decision making is distorted from improving the delivery of frontline care.  Instead, it is replaced with an upward-looking agenda, seeking to meet the wishes of regional and national NHS leaders and politicians.

Operating as a single, national, political NHS creates huge diseconomies of scale as external pressures consistently pull against local decision making made in the local interest.  The only part of the NHS that has been able to resist this and operate effectively and efficiently for its own patients is general practice.

The integration agenda assumption that what general practices needs is to be bigger and a more formal part of the NHS in order to join up care around the patient is one that needs to be seriously challenged.  Real integration requires decision making by those with a direct understanding of local needs, and the existing model of general practice is far more suited to that than the way the rest of the NHS operates.

17
jul
1

The Future of ARRS

Posted by Blogs, The General Practice Blog1 Comment

Wes Streeting pledged to review the ARRS scheme should he become health secretary, and now that he is it seems highly likely that the rules around this funding will be relaxed.  What might such a change mean?

The GPC is adamant that the ARRS scheme should be changed.  I have written previously about the absurdity of the NHS position that any use of the ARRS funding must prove additionality when core funding has been so drastically cut.  This has created the current situation where practices cannot afford the GPs they need (even when, for the first time in recent years, there are actually GPs available) because of the financial pressure on the core contract.  Meanwhile, the ARRS funding is protected and so can only be used for new/additional roles.

So it feels like this is an easy quick win for the incoming government.  Changing the rules won’t cost them anything (because the money is already there), and with no investment for general practice seemingly identified in Labour’s fiscal plan then some concessions will be needed if Wes Streeting really does want to prevent any potential industrial action by the profession.

However, making such a change does not come without its challenges.  Many of these have been eloquently identified by my PCN Plus colleague Tara Humphrey.  If core funding is replaced by PCN funding we might simply be masking the overall practice underfunding issue, creating a short term solution that although it may be welcome may serve to actually undermine the partnership model.  It could potentially make practices unsustainably dependent on PCNs (or are we there already?), which in turn could increase any existing tensions between practices and PCNs.

The other issue is the potential impact on the existing additional roles.  The ARRS funding is largely spent, as for the first time this year there is no growth in the ARRS pot.  So where will the money for the GPs and practice nurses (should they be added to the scheme) come from?  Will it be from any underspends that remain, plus any in year turnover (but how many GPs will that fund?), or would it actually result in some of the existing staff in post losing their jobs so that they can be replaced by GPs and practice nurses?

We could very easily end up in the situation where practices and PCNs are forced into some difficult decisions about which of the existing ARRS staff they want to keep and which are the ones they want to lose in order to fund GPs and nurses.  Some PCNs are likely to be more radical in the changes that they would be willing to make than others, and uncertainty and anxiety would undoubtedly spread across all of the ARRS roles.

But there could a significant upside for the existing ARRS staff if GPs were added to the scheme.  Whereas now in some places ARRS staff shift from practice to practice trying to add value where they can, they could be galvanised into a high-functioning team with the addition of dedicated GP leadership.  Instead of patchy, inconsistent supervision the addition of GPs could lead to the quality and quantity of support that these roles need to be able to come into their own.

The devil will be in the detail of any revisions to the guidance.  The extent to which “additionality” rules are still applied, any restrictions on practice-specific versus PCN-wide work, along with any financial limitations are all likely to shape how any changes to the scheme play out in future.  What is clear, however, is that any changes will need to be delicately handled in order to maximise the potential benefits without creating greater problems elsewhere.

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