8
sep
0

What Next for General Practice Nursing?

Posted by Blogs, The General Practice BlogNo Comments

General Practice nursing has reached something of a hiatus: the ten point action plan published in 2017 has expired and as it stands there appears to be nothing new taking its place.  At the same time the Primary Care Networks (PCNs) dominating much of the general practice agenda make relatively little mention of the nursing workforce.  So where does this all leave general practice nursing?

At the time of the publication of the General Practice Forward View in 2016, along with the subsequent 10 point action plan for general practice nursing, there was a gentle optimism that the problems within the general practice nursing profession were finally being recognised, and action was being taken to resolve these.  But fast forward to five years later and it seems the situation remains critical.

While the numbers of nurses attracted into general practice has risen over the last few years (NHS Digital data reports just over 24,000 nurses in 2020 compared to c15,000 in 2015), the fundamental problems in relation to retention of these nurses remain.  The aging workforce, the lack of career opportunities, and the generally poor support for nurses all contribute to the retention challenge.  General practice nurses are funded via the core general practice contract, have no direct influence on the contract negotiations and are not part of agenda for change, and the inequity of pay this generates is the source of much frustration.

PCNs have not helped.  Many nurses are angered by the lack of mention of general practice nursing in the PCN documentation, in particular in relation to the additional roles coming in via the PCNs.  It makes already undervalued nurses feel even more underappreciated, while other professions brand new to the sector receive all the support and attention.

Nurses have provided the frontline of face to face care in many practices during the pandemic.  While many clinical staff were able to function through the use of remote consultations, it was often nurses who had to continue the face to face work such as immunisations and vaccinations, right at the time when the situation was at its worst.  The Queen’s Nursing Institute’s General Practice Nursing Report published last year includes many individual examples of this, and there is no doubt that many GPNs felt exposed to increased risk compared to other workers.

Where does all of this leave the profession now?   Ironically, the introduction of the other roles, and the challenges associated with this, has reinforced for many GPs the value of GPNs.  It is a source of frustration for GPs as much as the nurses that they cannot use the ARRS funding to strengthen this particular workforce.  Despite this, there should still be a place within PCNs for practices to consider how they are supporting their nurses alongside the other roles.

The nurses themselves also have a role to play.  Mel Lamb, a recent podcast guest, describes the need for a change in mindset from the nurses themselves to be more proactive about the opportunities that do exist, and to take more of a leadership voice in how general practice operates.  We have seen the emergence of the Institute of General Practice Management in the last year creating a national leadership voice for practice managers, and it does seem that a similar kind of unifying impetus is needed for GPNs.

National support and action is also required.  It is impossible to look at where we are now, review the progress made over the last five years and decide the job is done.  It cannot be left to the discretion of local areas to determine whether any more action is taken.  There has been some great work started via training hubs, federations and other organisations and these need to continue to be supported and funded, alongside a proper focus on how this critical staff group can be retained, to ensure any gains made are not lost in the next five years.

1
sep
0

What to Make of the New PCN Guidance

Posted by Blogs, The General Practice BlogNo Comments

NHS England has recently published new guidance for PCNs, which covers the requirements for PCNs in relation to the DES specifications and how the Investment and Impact Fund will work for the 18 months from October.  This week I explore the implications of this guidance for PCNs.

Additional funding for PCN leadership and management support (£43m this year) is announced.  While PCN Clinical Directors certainly need more management support to help them with the role, this funding has to be taken with two important caveats.  First, there is no indication as to whether this funding is recurrent or not, and second there does not appear to be any extension of the additional Clinical Director funding itself (which had been increased for the first 9 months of this year).  So rather than “additional funding” it could probably be more accurately described as a re-badging (and reduction) of funding that PCNs are already currently receiving.

What is certainly good news is the announcement that PCNs will not be expected to deliver all of the additional PCN DES service specifications from 1st October, as had previously been signalled.  PCNs have to start with two: CVD prevention and diagnosis and tackling neighbourhood health inequalities.  Even these have been given an 18 month implementation timetable, meaning that the requirements for the first six months are not the full specifications.

Alongside this, the guidance announces the requirements for the anticipatory care and personalised care service specifications for 22/23, meaning PCNs are able to prepare for these now.

Of course the question all along has been where the funding for the additional work in each of these specifications is coming from.  What has become clearer with this publication is that the Investment and Impact Framework (IIF) is intended to provide direct funding support (or ‘incentives’ as NHS England like to term it) for the specifications.  Previously just over £50M had been allocated for the indicators in the IIF from April, but now new indicators have been added from 1 October that take the total national investment to the previously promised £150M.

As an aside, I find talking in these national, aggregated figures extremely unhelpful.  I understand it works for politicians and national figures when they are trying to demonstrate they are investing in general practice, but what a PCN needs to understand is exactly what it means for them (or even for an ‘average PCN’).  The original (£50M) IIF funds meant just over £40,000 was available to the average PCN, and this effectively triples that now this year to just over £120,000 for the average PCN.  In 2022/23 the total available increases to £225M, or £180,000 per PCN.

In the revised IIF there are a total of 666 points now available in 21/22 across 19 indicators.  This jump from just 6 indicators at present will need managing by PCNs.  80 of these points are allocated to the CHD specification (i.e. around £14,500 per PCN) and 56 to the health inequalities one in 21/22 (around £10,000 per PCN).  This does stand in contrast to the 222 points allocated to improving access to primary care services (or 166 if you don’t want to double count the health inequalities indicator, although even that indicator is not about tackling health inequalities per se, but rather health inequalities specifically in relation to access to GP services).

This latest guidance highlights that the focus on access to general practice is firmly back on the agenda.  I am not sure it ever really went away, but PCNs took primacy over access in national policy making for a couple of years, but we are certainly seeing it make a comeback now.  NHS England have produced this chart that summarises ‘PCN objectives’ for the next 18 months, and out of nowhere ‘improving patient access’ has appeared as one of the top 5 objectives for PCNs.  At the same time, supporting and sustaining core general practice is notable by its absence from this list.

Guidance had been promised on the transition of commissioning extended access services from CCGs to PCNs in the “summer” of 2021.  This letter states that this will now be available in “autumn”, but the deadline for the transition remains as April 2022.  This guidance was due last year, and has now been put back again, so it is clearly proving difficult to agree.  NHS England is probably stuck between a rock and a hard place with the government demanding more and more in relation to access, and the GPC unwilling to agree that PCNs will deliver more for less.  In the meantime PCNs are expected to have “undertaken good engagement with existing providers”, which in the absence of any guidance or indication of funding levels is something of a nonsense.

So that’s it.  There was always going to be a scaling up of expectations on PCNs, and we are starting to see this now.  It will soon be impossible for PCN CDs to manage PCNs on their own, simply because of the scale of the demands and delivery responsibilities upon each PCN.  For PCNs to work they need to do more than just what NHS England wants them to, as they also need to make a difference to their own member practices.  This latest guidance reinforces the need for PCNs to make sure they have they have clearly set their own priorities (so as not to be simply swamped by the national ones) and have the infrastructure in place to meet the ever-expanding requirements placed upon them.

25
aug
0

Is General Practice Making the Most of CCG Clinical Directors?

Posted by Blogs, The General Practice BlogNo Comments

Over the last 8 years a wealth of skills, knowledge and experience has built up within a relatively small group of GP leaders who took on Clinical Director roles within Clinical Commissioning Groups (CCGs).  Now that CCGs are coming to an end, what will happen to these Clinical Directors?

The first thing to say is that some CCG Clinical Directors have taken matters into their own hands and have taken on roles as PCN Clinical Directors, thus cementing their place in the new system.  But there are still a considerable number continuing to undertake their CCG roles whose places are less clear moving forward.

The context this sits in is the shift of the system as a whole from a commissioner provider split to one of integrated care systems (ICSs).  Within ICSs the different providers are expected to collaborate and work together to decide how care will be delivered and how resources will be deployed.  One of those providers is general practice.

Many of the functions of CCGs are transferring directly over to the new NHS ICS bodies.  It may well be that roles have or can be identified within these bodies for the GPs in CCG Clinical Director roles.  But the key question is whether general practice as a whole wants these GPs to be deployed providing clinical advice and leadership across the system within the ‘neutral’ NHS ICS bodies, or to be more squarely deployed as part of the leadership team of general practice?

Within CCGs GP Clinical Directors have an explicit remit as GP leaders within GP membership organisations responsible for the health of the whole population.  Within an NHS ICS body, it is less clear that any clinical leadership role should be filled by a GP.  They could just as legitimately be filled by clinicians from anywhere across the provider landscape.

If general practice is to genuinely operate as an equal partner with an equal voice within ICS discussions, it will need leaders who are able to develop strategy, think strategically, and operate politically.  These are exactly the skills that CCG CDs have been developing over the last 8 years, and are not skills that commonly exist amongst the provider-based GP clinical leadership teams.

The Consultant leadership within an acute trust is primarily deployed in medical and clinical director roles within the hospital.  It is only when these roles are filled that it will start to consider supporting system roles.  General practice is in danger of having this the other way round: making sure the system roles are filled before ensuring it has the internal leadership skills and expertise it needs.

History is, inevitably, getting in the way.  GPs who have undertaken CCG Clinical Director roles are sometimes perceived as being distant from core general practice, particularly when they may have been on the commissioner side of developing services and specifications that practices may not have been happy with.

Equally funding is a barrier.  CCG Clinical Directors were well remunerated for their time, and there is no obvious source of remuneration for GP leaders outside of the PCN Clinical Directors at present.

But general practice in every area needs to think through how it is going to be effective in the new world of ICSs.  CCG CDs are a hugely valuable resource for general practice, and the service as a whole would be well advised to consider how it can ensure that this resource is deployed where general practice needs it, rather than passively allowing the system to decide where it should go.

18
aug
1

How Does the System View General Practice?

Posted by Blogs, The General Practice Blog1 Comment

When you are working day in and day out in general practice, it is easy to lose any sense of perspective as to how the profession is viewed by those elsewhere in the system.  What do others think of general practice, and whatever it is, does it matter?

The reality of the purchaser provider split has meant that the views of others has not really been an issue for a long time.  Whether the local hospital or council ‘rate’ general practice has been neither here nor there, as the contract is primarily negotiated nationally, and locally there has always been a strong GP presence within the local commissioners.  This of course was baked into the design of Clinical Commissioning Groups, and was a staple of its predecessors Primary Care Trusts and Primary Care Groups.

Now things are about to be different.  The premise of Integrated Care Systems (ICSs) is that they are a collaboration between providers, who will agree between them how to design services and deploy resources.  The requirement for ICSs as legal entities to have GPs within their design is limited to say the least – one GP on an NHS ICS Board (not as a representative of the profession), and PCN involvement in place based arrangements (more explicitly to represent primary care).

The national GP contract will remain.  However, increasingly we are seeing any additional resources deployed through PCNs rather than direct to practices.  This trend will continue until 2024, and most likely beyond that.   This means (amongst many other things) the deployment of local resources to general practice will be essential, via enhanced services and the like.  The extent to which this happens, however, will be down to the local ICS.

The local ICS will be comprised of the various system partners.  The acute trust, the community trust, the mental health trust and the local council will be extremely powerful voices within the new arrangements.  So it will matter, for the first time in many years, how general practice is viewed by these partners.

How do those across the system view general practice?  Do they view it as a trusted partner, as a service that is worthy of investment, as the front line in the delivery of health and care?  Will the primary motive of each ICS be to invest as much resource as possible into general practice to improve the functioning of the system as a whole?

Of course views will vary across the country, and there will be a range of perspectives that are held.  The views will locally be influenced by personalities and the strength of relationships that exist at senior levels with local systems.  In some places GPs have rubbed local political leaders up the wrong way over a number of years, whereas in others extremely strong relationships have developed.  The credibility of the senior GP leadership inevitably affects the credibility of the service as a whole.

The underlying concerns that system leaders in some areas hold about general practice, whether they are valid or not, is the extent to which investment in general practice leads to any real returns.  There are concerns as to whether general practice is pulling its weight when it comes to the pressures on the urgent care system, with many (particularly in acute trusts) viewing the stories about lack of availability of GP appointments as a direct cause of downstream system pressures.  Council leaders on the other hand often bemoan the lack of impact the recent investment into general practice has had on health inequalities, and can sometimes hold the perception that practices are more motivated by money than by making a difference to the populations that they serve.

All of this can lead to an overriding sense from some system partners that general practice collectively is dysfunctional and fragmented, and that the consequences of this are felt by other parts of the system.

Don’t shoot the messenger!  In your area everyone may hold general practice in particularly high esteem.  There is no question that many have been impressed by the role general practice has played in the roll out of the vaccination programme.  But it may still be worth checking.  How others view general practice is more important now than it has been for at least 20 years, and where there are negative and unfounded perceptions in place it is critical that general practice takes action to start to correct these.  If it does not, life in the new system could start to prove very difficult indeed.

11
aug
0

What is the Role of LMCs in Integrated Care Systems?

Posted by Blogs, The General Practice BlogNo Comments

As we move into the new system of Integrated Care a question is emerging around the role of LMCs, and how it will be impacted by the change.

In a traditional purchaser provider model it makes lots of sense to have someone whose job it is to negotiate contracts on behalf of the provider.  Hospital trusts have contracting teams, and general practice has the GPC nationally and LMCs locally.  LMCs have a statutory duty to represent GPs at a local level, and are mandated to represent and negotiate on behalf of their local GP practices.

Whilst recognised by statute and having statutory functions, LMCs are not themselves statutory bodies.  They are independent, and it is this independence that means most GPs and practices trust their LMC to stand up for and support them.  Current legislation includes a requirement for NHS Bodies to consult with the LMC on issues that relate to general practice in their locality.

However, the new guidance on Integrated Care Systems states,

“It should be recognised that there is no single voice for primary care in the health and care system, and so ICSs should explore different and flexible ways for seeking primary care professional involvement in decision-making.” p27

It then goes on to say,

“PCNs in a place will want to consider how they could work together to drive improvement through peer support, lead on one another’s behalf on place-based service transformation programmes and represent primary care in the place-based partnership. This work is in addition to their core function and will need to be resourced by the place-based partnership.” p28

LMCs are not explicitly mentioned in the guidance.  The implication of the paragraphs above is that it will be PCNs representing primary care (i.e. not LMCs), and it will be up to each local area to decide how LMCs should be involved.

The challenge is that fundamental to integrated care is the need for collaboration and joint working between partners.  This requires give and take on all sides, something LMCs will find difficult because their mandate is only for general practice, and it would be hard for them to justify making concessions around the role of general practice for the greater good to their member practices.  The reality is most LMCs would not, and it is for that reason that those establishing place based arrangements in most areas will be reluctant to include LMC representation.

But if the LMC are not included it potentially serves to make life difficult for those who are representing general practice within the integrated care arrangements.  It is going to be hugely undermining if the representative agrees something for general practice, only for it to be rejected by the LMC (and then most likely member practices) at a later stage.  It won’t just be undermining for the individual leader, it will actually serve to undermine the voice and influence of general practice within the system, as it will reinforce the lack of confidence that some parts of integrated care systems have in general practice.

Any system that is formed as a collaboration of different organisations will necessarily be political.  Integrated Care Systems will be no different.  If general practice is going to be effective within the new systems it will need to find ways of bringing LMCs and PCNs (plus federations and any other general practice leaders) together itself, so that it can operate collectively and effectively.  The system is not going to do it for general practice, and unless general practice can create its own internal coherence it is at risk of having little or no influence on the new system as it develops.

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