20
jul
0

The Direction of Same day Appointments

Posted by Blogs, The General Practice BlogNo Comments

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.

13
jul
0

Can General Practice Operate Collectively?

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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.

6
jul
0

Is General Practice About to Score an Own Goal?

Posted by Blogs, The General Practice BlogNo Comments

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.

29
jun
0

Why general practice needs to act now

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This week will mark the end of the current system of Clinical Commissioning Groups and the commencement of the new system of Integrated Care Systems (ICSs).  It also represents the opening of a window of opportunity for general practice to take action that might not last for very long.

Many consider this current round of system changes to be just another turn in the wheel of NHS structures, the latest in a line of changes that have been happening every few years for at least the last 20 years.  But my sense is that this is a much more fundamental change, and one that could mark the beginning of an (even more) difficult period for general practice.

The end of CCGs marks the end of the purchaser provider split and the internal market that has been the organising principle of the NHS since 1990.  Alongside that principle has always been the idea of a primary care led NHS, and this also is coming to an end.  Instead, ICSs are based on the principle of providers working together, but of course not all providers are equal and the dominance of trusts and in particular acute trusts creates huge risks for general practice around priorities, contracts and funding.

How can general practice future-proof itself within the new system?  What action can it take?

The good news is that it seems that there is unlikely to be a nationally prescribed ‘solution’ for general practice.

When the system talks about needing a solution for general practice it means how can it work with general practice playing its role as a partner provider in developing system-wide responses to the challenges local health systems face.  With the GP leadership role of CCGs gone, there is no obvious route for working with general practice.  When there are upwards of 50 practices, 10 PCNs, and maybe 2 or 3 federations and LMCs in any area it can be virtually impossible to find any kind of consensus across general practice, let alone a shared commitment to collective action.

Despite Sajid Javid floating the idea of GP nationalisation earlier in the year, and the incorporation of general practice into an existing NHS organisation as the best solution, the Fuller Report very much points towards the development of local solutions for general practice within each system context.

The challenge for general practice, then, is to demonstrate that is can organise itself in any given area, that it can be united, and that it can create a consistent and influential voice.  If it can do this effectively, it can future proof its own autonomy as there is no need for the system to go down the route of asking another organisation to take over control.

But there is no time to waste.  It wont be long before ICSs find their feet and start to try to impose solutions upon general practice.  While currently this might seem well outside their control, if funding for general practice shifts from national to ICS level then they will most likely have the levers to be able to make this kind of change happen.

There are plenty of areas up and down the country already working hard to try and create a local cohesion across GP practices and organisations.  It is really important that everywhere starts to consider how to develop this in their area.  If practices do not start this work now, it may end up being too late and someone else may be brought in to do it to them.

22
jun
0

The Future of General Practice funding

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Hot on the heels of the Fuller Report, there is now talk of a reform of general practice funding allocations, all of which is pointing to some big changes coming for how the money flows to general practice.  What exactly do we know, and what is likely to happen?

Let’s start with the Fuller Report.  This says a number of interesting things when it comes to funding.  It reiterates the point made by NHS England recently when it says, “We welcome the clarity from NHS England that staff in post will continue to be treated as part of the core PCN cost base beyond 2023/24 when any future updates to the GMS contract are considered” (p19).

This is welcome, as many had been concerned that general practice would be expected to pick up the staffing bill for the ARRS staff post 2024.  It is noteworthy, perhaps, that the description is of these staff being part of the  “PCN cost base”, given the push for PCN funding to come via ICS’s in future that I will come on to.

The report also indicates that no change is planned to general practice funding until after the current five year contract has run its course – the recommendations on p35 around funding are that they should take place “beyond 2023/24”.  Nikki Kanani’s recent comments were also all about planning for the next contract after the current 5 year one.

However, the big push in the Fuller Report is for primary care funding, including general practice funding, to shift from being nationally to locally driven.  The report states, “National contractual arrangements, including for PCNs, have provided essential foundations including for chronic disease management and prevention. But they can only take you so far. As already highlighted in the report, getting to integrated primary care is all about local relationships, leadership, support and system-led investment in transformation. ICSs putting in place the right support locally will be enabled by maximising what control ICSs have over the direction of discretionary investment. This should be looked at by NHS England as part of the implementation of recommendations.” (p28).

Now in case that was missed by anyone the report was accompanied by a letter from the 42 Chief Executives of the new ICSs which reinforced this very point, repeating it almost verbatim, “National contractual arrangements, including for PCNs, have and will continue to provide essential foundations. But they can only take you so far. Getting to integrated primary care is all about local relationships, leadership, support, and system-led investment in transformation.”

There will undoubtedly be a variation across the ICS CEOs in how they view primary care and the role it can play.  But what they can agree on (unsurprisingly) is that they would like the funding for general practice to come via them rather than via a national contract.  It is hard not to believe that this shift of funds was at least to some extent behind the universal support ICS CEOs displayed for the report.

The extent of this shift is made clear in the annex at the very end of the report.  They want firstly the Additional Role Reimbursement Scheme to be delivered via ICSs not via a national contract (“Specifically consider, with DHSC and HEE, how the (ARRS) scheme should operate after March 2024, including the role of ICSs in working with national colleagues and PCNs in delivering it” p35), and secondly any additional funding for general practice to come under the control of local systems (“Move to greater financial flexibility for systems on primary care… Beyond 2023/24, maximise system decision making on any future discretionary investment, beyond DDRB and pay uplifts” p35).

The report also sets the context for Nikki Kanani’s comments at the recent NHS Confederation Expo about reviewing the national funding allocation formula as part of the contract negotiations for the next contract from April 2024.  The report says, “It is also generally accepted that the distribution of primary care funding to neighbourhoods is not always well aligned to system allocations and underlying population health needs – and we need a concerted local effort to try and fix this.” (p28).

All of this, then, is pointing to a shift of resources out of the national contract after this 5 year deal expires, with far more to be allocated via ICSs.  The distribution of this additional resource (it seems) will be made by ICSs dependent on population health needs, regardless of the specific local needs of primary care providers.

All of this means there are a number of risks ahead for general practice.  First, ICSs are governed by a requirement to break even across the system, and cannot ringfence funds in the way areas could in the previous system when commissioners held individual contracts with providers, so funding via an ICS cannot be guaranteed in the same way as funding via a national contract.

Second, the allocation of locally distributed funds is likely to be based on population health need, meaning the distribution across practices will vary significantly.  Third, the ability of general practice to influence the direction of funds within a local ICS is far less than its collective ability negotiating a national contract together.  Fourth, there does seem to be some form of play for some of the existing PCN resources to shift out of the national contract and into local control.  And finally once resources are within ICS control they don’t have to come direct to general practice but could come via a partnership mechanism, i.e. via a third party provider of “support” such as an acute or community trust, which would likely further impact on the independence and autonomy of general practice.

My view for what it is worth is that general practice should think extremely carefully about agreeing to any significant shifts of funding from the national contract into local systems, but the GPC appears to be positioning itself badly in this regard with its position on the PCN DES, and so whether the service ends up with any choice in the matter remains to be seen.

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