Making the Transition from Commissioner to Provider

The impact of the formal establishment of Integrated Care Systems and the abolition of CCGs may not have been felt straight away, but there is no escaping the huge consequences this has for general practice.  The question is whether general practice can shift from influencing as a commissioner to influencing as a provider quickly enough to prevent any real damage being done during the transition period.

For the last 30 years, ever since the introduction of the internal market, the influence of general practice has grown through the commissioning route.  It started slowly at first, with the initial forays of GP fundholding, but then steadily grew until Clinical Commissioning Groups were established built around a membership of GP practices.

While the influence of general practice grew through the commissioning route, its influence as a provider steadily receded.  A strong provider voice for general practice has not been needed because GP leaders were already at the system table via the CCG.  Indeed, GP provider representation was actively discouraged because of concerns around conflict to interest.  At best we had GP federations and GP provider organisations purporting to be the voice of general practice provision, but in reality they represented additional provision undertaken by these organisations above and beyond core general practice.

This has been of little concern to the profession because the main representation of general practice takes place nationally via the negotiation of the national contract.  It is this contract that has been pivotal to the sustainability of the service, much more important than any additional local income.

But now this is a problem for two reasons.  First, the representation of general practice at a national level is finding it difficult to secure an effective deal for the profession.  This is encapsulated by the self-defeating policy to promote the withdrawal of practices from the PCN DES, despite all the agreed additional resource for general practice over the last 5 years coming via this route.  This creates a huge risk for general practice, because it relies on a premise that this funding will be reinvested into the core contract instead, when a much more likely outcome is simply that practices will lose control of the PCN resources.

Second, all the signs are that much more practice income will come via the local route rather than via the national contract in future.  This was signalled strongly in the Fuller Report, and backed up by a letter from all 42 ICS Chief Executives.  If this is the case, how organised is local general practice to negotiate as a provider with its local system.  Are LMCs up to the job?  Is the infrastructure of LMCs sufficient for the size of what may be required? While some clearly are, there is a huge variation amongst LMCs across the country.  The system is going to want more ‘integration’ by general practice in return for more resources, so how are PCNs going to play into these discussions?  Will PCNs and LMCs be joined up, or will they be played off against each other?

For the first time in over 30 years local general practice needs to establish its voice and influence as a provider in the local system.  The support that has historically been in place from commissioners will quickly recede in the new system.  Much of the responsibility that has sat with national leaders and the national contract will become the responsibility of local leaders.  It will be up to general practice in each local area to support itself.  LMCs, PCNs, federations and practices will need to work together to ensure local general practice is unified.

Can GP Federations Continue to Stand Alone?

The world is moving quickly and the need to take a step back and consider how everything fits together is becoming more and more frequent.  For GP federations the move into Integrated Care Systems (ICSs) is creating one of these moments.

Historically GP federations have been set up in local areas often by a relatively small number of enthusiastic GPs.  They generally began with high expectations, and then over time relationships with member practices have waxed and waned, particularly as it has been challenging for federations to fulfil the delivery requirements needed to establish themselves as a provider and at the same time carry out the amount of communication necessary for practices to feel engaged and part of the organisation.

Then along came PCNs.  Up until that point it had been easy for federations to describe themselves as the ‘at-scale’ arm of general practice, as there were only individual practices and the federation.  But with PCNs came a mandated at-scale operation of general practice in every local area.  Now there are practices, PCNs and a federation, and it has made it more difficult for federations to articulate their role in the system.

The preference has generally been to describe themselves as the at-scale provider across any given area, as their remit tends to mirror old CCG areas and hence be larger than nearly all individual PCNs.  The mainstay of many federations has been the delivery of extended access, and recently federations and PCNs have been undertaking a round of relatively strained conversations to agree what the federation will do and what PCNs will do, now that responsibility for the service has shifted to PCNs.

But it is the emergence of ICSs that is bringing things to a head.  General practice needs to be able to operate as a collective entity within an ICS “place” area.  Within such an area there is often a number of PCNs, an LMC and (if one exists) a federation.  The question is whether, in such an environment, a federation can stand alone as a GP provider organisation, separate from core general practice?

This is problematic because the system wants to do business with general practice as a whole (not a limited company that can access GPs to deliver services).  Whereas in the past federations could point to their practice membership as a proxy for working across all practices, with PCNs in place this is no longer the case as they have a much clearer practice membership.  Federations were never really set up as a way of other organisations being able to do business with general practice, so now federations have a problem.

The most obvious way forward would seem to be to strengthen the federation/PCN relationship.  If federations can be the glue that holds PCNs together they would be perfectly placed to continue to provide at-scale services, provide support for PCNs and practices, and by including the LMC could start to be able to talk with authority in the system as local general practice.

But while some federations have been bolder in taking steps towards taking on the provision of support for PCNs as a new part of its core business, many have shied away from this (often because of emerging PCN/federation tensions, and because of the costs involved).  While PCNs are funded by the PCN DES, federations rely on funding from the delivery of services.  The need to breakeven/fund the federation infrastructure and even generate a return for shareholders has often created a tension in terms of what federations have been willing or able to do in terms of support for PCNs.

The irony is that federations are highly unlikely to be able to generate any kind of sustainable financial return if they maintain their separation from PCNs.  They will increasingly rely on the PCNs for the work (like extended access), and if federations are not the support provider for PCNs then whoever takes this on will end up being better placed to take on any at-scale work.

Without the protection of CCGs the ICSs are not going to tolerate small-scale provider organisations with no real remit.  If federations are not providing the scaled up support the new integrated neighbourhood teams are going to require, and don’t become the organisation that holds general practice together in an area, it is hard to see how they will survive beyond the next few years.

The Direction of Same day Appointments

There is no escaping the issue of access to GP appointments.  Now more that ever it is sitting at the top of the national priority list, so what can we expect the future to look like?

There is seemingly a media campaign highlighting the challenge many patients face in obtaining a face to face appointment with their GP (e.g. here).  The highly public nature of this issue means that it is the government’s highest priority for general practice.

At the same time, the erroneous belief that the reason emergency departments are struggling is because patients cannot get to see their GP pervades Integrated Care System (ICS) thinking.  The priority for ICSs is now to ensure that ‘something is done’ about this issue.

This was the context that the Fuller Report was produced in.  Despite the framing of the report as “a vision for integrating primary care”, the framework for shared actions is clear that the number one priority is to, “Develop a single system-wide approach to managing integrated urgent care to guarantee same-day care for patients and a more sustainable model for patients” p34.

I have written already about the single urgent care teams the Fuller Report proposes.  In this article I noted the lack of clarity in the report about exactly what was intended by the notion, and that much of what was written raised more questions than answers.  However, talking to different people it seems that there is a likely direction of travel.

PCNs are already putting plans together to outline a single model of delivering extended access across each PCN to start in October.  The requirement for on the day demand to be organised across the practices in a way that integrates all of the service offerings and guarantees same day care will be added on to PCNs.  The logical third part of the jigsaw will be to also give responsibility for out of hours care to the PCN.  Thus PCNs will have responsibility for 24 hour delivery of urgent primary care in their area.

PCNs meanwhile will most likely fall much more under the remit of ICSs.  Their rebranding as Integrated Neighbourhood Teams and shift of funding from the national contract to ICSs will mean that performance management will come locally.  Don’t expect this to be as light touch as we have seen in many areas over the delivery of the PCN DES specifications.

This of course has huge implications for practices.  While many areas are working on plans for extended access that minimise disruption for practices (either stick with the existing provider, or enable all or part of extended access to be delivered by practices where there is capacity/will to do so), the same approach is not going to work for in hours appointments where many practices are not able to offer same-day appointments.  GP capacity is insufficient and falling, so a different approach, one that most likely involves the patients of individual practices being seen either in PCN ‘hubs’ or by other practices, will be needed.

For some this will represent an unacceptable move away from the core model of general practice, where individual practices deliver cradle to grave care for their list of patients.  This new model creates limits on where continuity of care is required, and splits urgent access away from the traditional model.  For others it will be a welcome relief from the incessant demands placed on the practice, with no hope of them ever being met.

It seems we have a rocky road ahead.  Many PCNs have found getting to agreement across practices on extended access challenging enough, and the prospect of doing with the same with in-hours on the day demand and potentially even out of hours extremely daunting.  Meanwhile, this will feature highly on the priority list of the new ICSs, and given the wider system pressures it would not be surprising to see many adopt a relatively heavy handed approach.  At the same time there will undoubtedly be a backlash across many parts of general practice because of the challenge it poses to what represents core general practice.

Whatever your views, I think it would be sensible for practices to start thinking about this issue now, and working out how they want the future to unfold.  Getting on the front foot, rather than waiting for the system to impose something on you, seems the best strategy to take right now.

Can General Practice Operate Collectively?

Whilst the starting point for general practice to be able to influence the new-in-place Integrated Care Systems (ICSs) is its ability to establish a unified voice, the challenge quickly follows as to whether it can also act and operate collectively.  But is this a bridge too far for independent contractors?

It is one thing for all the general practice organisations in any given area (practices, PCNs, federations, LMCs) to create a unified voice that it can provide into any system discussion.  General practice can create its own leadership team that can work to be the group representing the whole of general practice in an area.  This is an important and crucial first step towards establishing influence in the new system.

Once leadership groups are established they can very quickly become the place where the system and other organisations come to talk to general practice, a helpfully accessible route that has rarely previously existed.  They can also provide a viewpoint on the ideas, plans and strategies of others, and identify what general practice does and does not agree with.

But it is another thing for those general practice organisations on the leadership groups to be able to work together and agree how general practice as a whole will operate.  It is difficult for them to get to a place and agree that this is what PCNs and practices will do, this is what the federation will do and this is how we will oversee and ensure that what we have agreed is working.

Enhanced access is a good example of this.  The debate is often lost in internal general practice arguments as to which PCNs will do what, what the federation will do and how any ‘hybrid’ model will work.  Very few places have been able to establish and present a unified, coherent, local model with a single reporting structure that can feed into the wider system discussions around urgent care.

The Fuller report points to a model of managing urgent care that brings in-hours on the day demand for general practice, enhanced access, and out of hours care all together (Fuller Report p11/12).  This was number one in the list of actions for local systems to take (Fuller Report p34).  Can general practice agree for itself how this model should be introduced, or will it require the system to enforce a model upon it?

The problem is that practices, PCNs and federations are often focussed on their own autonomy and the needs of their own individual organisations, but this is coming at the expense of what is best for general practice as a whole.  For general practice to be able to preserve its overall autonomy, and resist system advances for it to be ‘integrated’ into some existing part of the NHS machinery, it will have to demonstrate to the new ICSs that it is able to organise itself.  The paradox is that individual general practice organisations will have to give up some autonomy in order for general practice as a whole to retain it.

Ultimately it will not be enough for general practice to create a shared leadership group if it cannot then convert that into collective action.  For influence to be real it needs to go beyond having seats at system meetings, because it is not really about how loud the voice is but whether it can actively impact what happens across the system.    Of course, general practice can have more of an impact than any other organisation on the system, but only if it finds a way to operate collectively.

Is General Practice About to Score an Own Goal?

I was amazed when I heard that the BMA’s Annual Representative Meeting had voted in favour of GP practice withdrawal from PCNs by next year.  The motion for the, “GPCE and the BMA to organise the withdrawal of GP practices from the PCNs by 2023” was passed with 61% voting in favour, 12% against and 27% abstaining.

The context for this is that we are currently in year 4 of a 5 year contract deal, agreed in 2019.  By the time we reach the point at which this withdrawal is to happen it will be for the last year of the existing deal.  The majority of the benefits of this deal for general practice sit within the PCN DES, and so the call is for general practice to withdraw from the part of the deal with the biggest benefits for its last year.

I cannot be the only one thinking efforts might better be focussed on negotiating the next deal, rather than putting a huge amount of effort into raising concerns during the last year of the existing deal.

We already know that NHS England is not going to negotiate around the existing deal.  Last year was the first year we did not have a negotiated agreement between the GPC and NHS England.  It will not be any different this year, as they will argue exactly as last time that the current deal was already agreed to four years ago.

The wider context is that we have Integrated Care Systems (ICSs) wanting to take control of GP and in particular PCN funding.  The system can see the extra money that is being put in through PCNs, and in particular through the ARRS, and wants to get its hands on it.  Remember £1.8bn of the additional £2.8bn negotiated in 2019 comes through PCNs.

This creates a fairly happy set of scenarios for NHS England.  They can offer to take PCN funding out of the national contract next year so that it can be “topped up” locally by ICSs, thereby increasing the funding going into PCNs and accelerating their development into Integrated Neighbourhood Teams (as per the Fuller Report).  Very little of any extra money would make it to practice level, and the cost would be a big shift away from a national contract and a worrying precedent set ahead of the next 5 year deal.

Alternatively NHS England can give the PCN funding to ICS areas directly (if practices say they do not want it), for them to either route back through general practice or put it through a local lead provider type model.  If general practice does not want the PCN money or staff, then the system I am sure will be happy to take it.  At this point it would be hard to see any other route for general practice to survive other than via integration into other providers.

The LMC motion that was passed in full also calls for, “PCN funding to be moved into the core contract”.  The problem is that this is outside of the control of general practice and is not something that NHS England or the government is going to agree to.  If what the system wants is a general practice that can actively partner with other providers then the last thing it is going to do is act to strengthen its independence.

Withdrawing practices from PCNs at this point in time would be a huge own goal for general practice.  I understand the resentment and dissatisfaction that exists within many practices towards PCNs, but if the aim is to preserve the independence of general practice then this is politically naïve and a move that will do far more damage than good.

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