How Much Governance is Enough for Primary Care Networks?

The relationship was over.  After a bright beginning things had slowly deteriorated, and now it was time to call it a day.  The problem was we had a house, a car, joint bank account, the works.  We were faced with a choice – get the lawyers in to fight it out, or sit down and work it out ourselves.

Would we have been better sorting out a legal contract at the beginning, so that in the event of this situation arising we would have had a framework to sort it out?

This is the question some practices facing the prospect of entering a Primary Care Network are asking themselves.  Two thirds of the promised new money for general practice is coming via these networks, and that may just be the start.  CCGs and STPs are likely to put nearly all future local enhanced services through these nascent networks.  The fates of each practice within a network will be intertwined.

With this in mind, the temptation is to establish some form of legal contract between the practices.  Yes there is going to be a model network contract, but is it going to be enough?  Networks are going to need every practice to pull their weight.  Would it be better to get them to sign up to both their commitments and, more importantly, the consequences if they don’t meet them?  Won’t that provide better protection for everyone?

Back to the end of the relationship.  We sat down and had the difficult conversation, and agreed who would be having what.  It felt like a better way to sort things out than paying expensive lawyers and asking them to decide.  We would have had to have the conversation anyway, but this way we had it face-to-face rather than through our legal representatives.  I don’t think an upfront legal agreement would have done anything other than breed mistrust from the very beginning and increase the likelihood of legal fees down the line.

If a practice in a network doesn’t pull its weight, doesn’t fulfil its commitments, or doesn’t do what it is supposed to do, all of the practices will lose out.  Stronger legal agreements won’t prevent the need to have the difficult conversation.  Better to focus on the work needed to avoid this situation in the first place.

Three things feel more important than investing in lawyers for practices at this stage:

  1. Build positive relationships. Develop enough trust between practices to be able to have the “difficult” conversation without getting the lawyers (or the CCG, or NHS England, or the LMC etc) in.  Time invested in relationships before these conversations are required will repay itself over and over if it means practices in a network can work through their own challenges and issues internally.
  2. Appoint the right GP network leader. Brokering these conversations is likely to fall to the appointed GP lead of the network.  Building bridges between the practices may well be the key challenge of these new leadership roles, and be much more difficult than the external facing requirements.  Appointing someone trusted by all of the practices will be key to future success.
  3. Get the size of the network right. Smaller may be better.  There has been an initial reluctance in certain quarters to move from pre-existing localities and groups of 70 or 100 or even 150 thousand populations into the new 30-50,000 limits.  There is a sense of safety in numbers in the larger groupings.  But the point of the new size is that it is small enough for everyone to know everyone.  At this size, building trust across everyone is more possible, and the leadership challenge less impossible.

One of the key strengths of general practice has been the family feel of the practices, and the close relationships between staff and with patients.  This is a strength practices should aim to build on as they move into networks, rather than abandoning personal relationships in favour of legal frameworks as a way of reducing risk.  Involving lawyers might feel like it is adding a layer of protection, but the reality is the success of the network will be based on the strength of the relationships, the quality of the leadership, and the ability to have the difficult conversations when they are needed.

What do Primary Care Networks Have to Do?

It is easy to get lost right now in the immediate challenge of identifying practices to be in a network with, persuading someone to be the ‘accountable clinical director’, and deciding who should hold the network bank account.  But to get these short term decisions right it is worth spending some time reflecting on exactly what primary care networks are supposed to do.

This starts with their place in the wider system.  The new GP contract says, “The Primary Care Network is the natural unit for integrating most NHS care. Collective general practice can become the footprint on which other NHS community-based services can then dock. And by serving a defined place, the Primary Care Network brings a clear geographical locus for improving health and wellbeing.” (p25)

How networks will start to enact this bold claim is also spelled out in the new contract.  There are seven services networks are to provide against national specifications.  After the set-up year of 2019/20, there are two initial services to be delivered in full in 2020/21.  Networks are to provide structured medication reviews to patients, focusing on particular priority groups.  The pharmacists employed during 2019/20 will be key to the delivery of this service.

They are also to provide a new enhanced service for care homes.  This might be the first new service requiring networks to agree differential delivery across practices, e.g. a lead practice for one or even all of the care homes.  A condition of signing up the network agreement is that services will be provided equally across the network population, and it is becoming immediately apparent networks won’t work via a simple equal division of labour across member practices.

Worth a further pause at this point.  Many CCGs up and down the country have commissioned these types of schemes locally.  It would seem the use of the national GP contract, and its new network function, will lead to the replacement of many locally commissioned schemes with nationally commissioned ones.  We should watch out for how much opportunity the imminent Network Contract DES indicates there will be for local flexibility.

There are three further services that are to “commence in 2020/21 and develop over the subsequent years”.  This is where general practice is taken into slightly less well chartered territory.  While the first service, anticipatory care, is fairly common across the country (although under different names such as “proactive care”) and the idea of identifying and proactively managing the needs of high risk patients is nothing new, what is new is that this service will require a “fully integrated primary and community health team”.   Community providers will even be asked from July to configure their community teams on primary care network footprints.  The relationship (and power dynamic) between the primary care network and the newly configured community team will be critical to future success.

Which takes us back to the wider purpose.  The network is very much about enabling the integration of primary care with other parts of the NHS system.  “A Primary Care Network cannot exist without its constituent practices, but its membership and purpose goes much wider. The NHS Long Term Plan sets out a clear ambition to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. The Primary Care Network is a foundation of all Integrated Care Systems; and every Integrated Care System will have a critical role in ensuring that PCNs work in an integrated way with other community staff such as community nurses, community geriatricians, dementia workers, and podiatrists/chiropodists.” (New GP contract, p30-31).

The next service is “personalised care”.  Easy to say, hard to understand exactly what it is.  I have read the relevant parts of the new contract a number of times and I still find it hard to pin down.  It seems this is essentially about widening the support provided to individuals beyond purely medical interventions.  Social prescribing and the newly funded link workers will play a prominent role in the delivery of this service.  However it plays out, it is another step in widening the scope and role of general practice through networks in influencing the overall health of local populations.

The last service to be introduced in 2020/21 is supporting early cancer diagnosis.  What is most interesting about this service will be the role of networks in raising awareness of symptoms and uptake of screening in their local neighbourhoods.  Networks may provide a way of practices operating more freely outside of their practices with local community partners.

Finally, in 2021/22 two more services will be introduced.  Cardiovascular disease prevention and diagnosis and, more nebulously, tackling inequalities.  Whilst the former is relatively clear, the latter much less so.  The text in the contract is along the lines of “we will test some ideas and then roll out the approaches that have the greatest impact at the network level”.

Alongside these seven new services from 2020 there will be a new national “Impact and Investment fund”.  Based on a principle of “shared savings” it means networks can gain a financial return from reductions in A&E attendances, emergency admissions, outpatient costs, prescribing savings, and hospital discharge (I assume via reduced length of stay), to then invest in new staff for the network.

It seems, then, the real work begins for networks in 2020 with the introduction of these specifications.  The immediate challenge then should not be simply to tick the relevant boxes that will be sent out by the centre, but rather to use 2019/20 to develop a platform that will be able to deliver against these future requirements, or even better one that can make a real difference to the health and wellbeing of the population it will be serving.

Who Should Host Your Primary Care Network?

I have talked a lot about needing to start with why and build relationships before you get into the discussion about what form your primary care network should take.  But time is short, and form is also a decision that will need to be made.

First things first.  £1.8bn of the promised £2.8bn coming in to general practice in the next five years is coming through networks.  It is worth spending some time making sure these are set up correctly!

Technically practices sign up to networks by signing up to the Network Contract DES (guidance due out in March).  Networks are not to be legal entities of themselves; the aim is explicitly not to create another layer of governance/bureaucracy.  In signing up to the Network Contract DES practices have to identify, by 15th May, “the single practice or provider that will receive funding on behalf of the PCN” (p27).

The contract goes on to say, in paragraph 4.32, that “It is for each PCN to decide its delivery model for the Network Contract DES.  It could be through a lead practice, GP federation, NHS provider or social enterprise partner”.

But which option to choose? How would a new network decide?  It is worth spending some time examining the pros and cons of each of the options.

  1. Lead Practice

Summary: This model feels primarily designed for those practices already at the magic 30-50,000 population, who wish to become a network in their own right.  The money stays close to general practice, but could be a fast-track to inter-practice disputes where more than one practice is part of the network.

Pros Cons
Allows a single practice to receive/manage all the network funding Funding routed through one practice can lead to tensions between practices
Keeps the funding as close as possible to core general practice Liability for expenditure (e.g. employment of new staff) sits with the host practice
Enables rapid decision making and minimal bureaucracy Limited ability to influence as wider general practice within local integrated care arrangements, or to develop services beyond network boundaries

Key questions to consider:

If the network has more than one practice: How will you ensure all practices have an equal say?  How will you ensure transparency between practices? How will you prevent it feeling like a pre-cursor to a future merger with so much of the funding flowing through one practice?

How will you establish joint working arrangements with other networks? How will you create a strong local voice for general practice with other networks?

  1. GP Federation

Summary: This model feels primarily designed for those practices who already have a successful GP federation in place, who want to use the federation infrastructure to strengthen the ability to deliver against, and maximise the opportunities of, the Network Contract.  It will require a clear accountability of the federation to the networks.

Pros Cons
Creates a GP owned host that will allow equity between practices in a network Given the timescales, is likely only to work where GP federations already exist
Creates opportunities for at scale working beyond network boundaries, e.g. extended access funding is often already routed through federations, development of services to impact the Investment and Impact Fund Federation may have priorities different to those of networks, e.g. delivery of existing contracts
Limited liability for the member practices of employing new staff if employed directly through the federation May feel like the networks work for the federation rather than vice versa if not structured correctly
Potential enabler of strong collective voice for general practice in local integrated care working Potential VAT issues if practices want to second existing practice staff into the federation

Key questions to consider:

How will you make sure the federation is working for the networks, and not vice versa?  Who controls the decision making in the federation?  Do/will the networks have enough of a say?  Is there a willingness among federation leaders to adapt the existing governance to meet the needs of networks?

  1. NHS Provider or Social Enterprise Partner

Summary: This model feels primarily designed for those practices already in some form of partnership arrangement with either the local hospital, the local community or mental health trust, or some other organisation.  Without an existing relationship in place it is hard to see how the level of trust could be high enough for practices to be willing to entrust their funding to them.

Pros Cons
May be able to provide additional services for networks such as estates or HR support Is only likely to work where a reasonably advanced existing agreement is in place between local practices and the host organisation
Large turnover organisations will be able to carry liability and any financial risk the networks want to undertake The size and core business of the organisations may mean the networks and their activities are low priority for them
May enhance ability to recruit and support new staff groups e.g. physiotherapists, pharmacists, where host organisation already employs these staff groups Voice of the networks may get confused with that of host organisation in system/integrated care discussions
May be able to offer synergies with own service offerings, e.g. integrating community and primary care teams Distance of the funding from practices

Key questions to consider:

What influence will the network have on the host organisation?  How will it be able to control how network funding is used?  Does the relationship rely on certain individuals, who may only be around for a few more years?  How can networks ensure they can retain a distinct identity from the host organisation?

Conclusion

It very much looks like different solutions will be appropriate for different areas, and that there is no obvious “best” solution that applies to all.  For single practice networks, or those already in a federation or who have a pre-existing relationship with another organisation, the challenge is probably mainly about adapting their existing arrangements to meet the network requirements.  But the greatest challenge may lie with those nascent networks who are formed of a group of practices, with no federation or obvious organisational link.  For them, the best way forward appears far less clear.

First steps towards networks

Maybe your practice has never worked well with other practices.  Maybe you have avoided it, as far as has been possible.  The new GP contract, with so much money going through the new primary care networks, means this strategy of avoidance is not going to be an option any longer.  What do you do now?

There is a perception that primary care networks are not really anything new, that they have been happening anyway.  I don’t think this is true.  According to the NAPC website, 16% of the population is covered by the forerunner of primary care networks, primary care homes.  NHS England state that according to CCG returns 80% of practices report being in some form of network.  A generous estimate might put the real figure of the percentage of practices that have actively sought to work with their neighbours in some sort of meaningful way in the middle of these two, which would be about 50%.

That means half of practices are in the situation of having to work with other practices for the first time.  It means while half of the practices are building on some sort of foundation, making progress, and generally intimidating those who don’t know what to do, half are simply trying to get their heads around what the new world of networks means.

I have spoken to a number of people recently, asking what advice they would give to GPs and practices in exactly this situation.  I asked an accountant, a lawyer and the Head of Primary Care at NHS England.  Interestingly, all three came up with exactly the same answer.  Go for a drink or for a meal with your local practices.  Get to know them.  Build the relationships.

The questions GPs and practices ask when reviewing new guidance or documents such as the new GP contract are often technical.  What will the accounting relationship be between the new network and my practice?  Will we incur VAT charges?  Who will employ the staff, and where will the risk sit?  These are all valid questions, but, even according to an accountant and a lawyer, they are not the place to start.

A few years ago a colleague of mine took up a new post as an Executive Director in a large teaching hospital.  On her first day she met with the CEO.  He said to her that he didn’t want her to do anything for the first month, just to build relationships.  She was stunned.  She wanted to prove her worth, and was worried that she would be seen as someone without focus on delivery.  But years later she reflected it was the best advice she could have been given.  She said too many people start to try to do things without having relationships in place.  Delivery then happens at the expense of those relationships, not through them.  But because she was given the time to develop strong relationships she was able to deliver far more than if she had just jumped straight in.

The same applies to GPs and practices looking to set up new networks.  The whole rationale of the 30-50,000 population size is about relationships.  It means the people operating within the network can all get to know each other and have a personal relationship, and not be of a size that inevitably creates distant, faceless bureaucracies.  So if the basis of the new primary care network is relationships, the best starting point is to build these relationships.  While it might feel indulgent when the timescales are short, time invested now will repay in buckets in the months and years to come.

Primary Care Networks: Start with the right question

The clock is already ticking. Following the recent publication of the new GP contract, GP practices only have until the 15th May to submit their network registration information to their CCG. Waiting until the Network Contract DES is published (promised by 29th March) will only leave 6 weeks. Starting now gives practices three months to get ready for the new networks.
But where to start? It is tempting to jump straight in to what the network will look like and how it will operate. But a better place to start is with “why?” Why will this network exist? What is its purpose? What difference is it going to make?

Simon Sinek talks about this lot. His book, “Start with Why”, has inspired many. For the time poor, you might want to cut straight to this 5 minute short version Ted talk to understand the essence of it. Essentially, people are inspired by a sense of purpose. It is this that motivates us to take action. Clarity on why we do things leads to much more sustained action than clarity on what we are to do or how we are to do it.

The GP contract offers a number of possible motivations for primary care networks. They are (p25):

  • “Intended to dissolve the historic divide between primary and community services”
  • “A way of helping GP partnerships survive and evolve over the coming decade, and provide a means of mutual support for better workload management”
  • “A dedicated joint investment and delivery vehicle”, a way of enabling investment into primary care where it cannot reasonably be expected for every practice to deliver the requirements on their own”
  • “Large enough to run a full multi-disciplinary team”, a way of bringing new roles into general practice”
  • “A clear geographical locus for improving health and wellbeing”
  • “To provide strategic and clinical leadership to help support change across primary and community health services”

Each area is different. One, some or all of these may work for you. More likely there will need to be some adaptation, some local tailoring, to create an ambition that is inspiring for your GPs and the practice staff in your network.

It will be easy to get lost in creating a network simply because you have to. Or in tactics to try and maximise income received. Or in the details of how the network will operate. But networks present a huge opportunity for general practice, not just for now but for many years to come. Decisions made in the next 3 months are like to have long lasting consequences because these networks will grow in importance.

Even though time is short, time invested now in determining the why of their network for member practices will be time well spent. It will create unity, excitement even, and a shared sense of purpose. It will make delivery down the line much easier, and sustain action well beyond the initial network submission deadlines.

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