What to Make of the NHS England “Freeing up Practices” Letter

Last week, on the 7th January, the national primary care team wrote a letter to practices entitled, “Freeing up practices to support COVID vaccination”.  There is no question GP practices are struggling right now, so how helpful was this letter, and does it go far enough?

The letter follows a previous letter written at the start of the second lockdown in November, which headlined with an announcement of £150M of additional primary care funding.  The core message of this letter was that, unlike the first wave of Covid, GP practices are very much expected to stay “fully open” this time round.  The additional funding was to enable “expanded capacity”, and to be able to deliver (on top of day to day work), extra work including:

  • Supporting the establishment of a Covid oximetry at home model
  • Identifying and supporting patients with long Covid
  • Supporting clinically extremely vulnerable patients and maintaining the shielding list
  • Making inroads into the backlog of appointments including for chronic disease management and routine vaccinations and immunisations

As a result the £150M has been primarily deployed to support additional work in general practice, rather than to provide any extra support for the work currently being carried out.

Two months later we are at a point where the pressure of the pandemic has significantly increased.  Practices are having to juggle staff sickness and isolation alongside skyrocketing demand.  At the same time the pressure is on from all sides for practices to carry out an extremely challenging Covid vaccination programme, as well as well as completing the biggest ever flu vaccination programme.  This is before getting started on the list of extra work from the November letter.

And so it was into this context that last week’s letter landed.  There is no question that the financial protections it contains were very much needed.  The minor surgery DES, the QOF QI domains and the 8 prescribing indicators in QOF are all now income protected until the end of March.  I think just seeing something that recognised the need for additional support prompted an initially positive reaction from many.

Non-essential locally commissioned services are suspended, although there is no guarantee of income protection.  Instead “budgeted payment against these services should be protected to allow capacity to be redeployed”, which undoubtedly will mean some CCGs interpret this as local income protection while others make additional requirements of practices against it.

PCN CD funding is (rightly) increased from 0.25 WTE to 1 WTE in recognition of the complexities of the Covid vaccination response.  This can “be flexibly deployed by PCNs” – it will be interesting to see how this works where one PCN is leading on behalf of a number of PCNs.

The other main announcement was that extended access funding won’t be shifting to PCNs before April 2022.  You would think that “repurposing extended hours and access capacity to support the vaccination programme” would actually be easier once the funding moves across to PCNs, but given everything currently happening I can see that many PCNs would struggle to put effective new arrangements for extended access in place any time soon.

My sense is that when you dig into the detail of the letter it does not acknowledge the reality of the additional pressure currently on practices as a result of both managing Covid patients and the demands of the vaccination programme.  If the national aim is really to free up practices to support Covid vaccinations, I would suggest what is also needed is:

  • The £150M announced in November is distributed to practices to enable them to manage the current demand rather than to create additional work for practices
  • There is a national mandate that the income from locally commissioned services is protected for practices by CCGs
  • PCNs are allowed to flexibly deploy the ARRS underspend to staff vaccination centres. The requirement for six month minimum contracts limited to the staff roles identified in the ARRS list feels like such a wasted opportunity.
  • National financial commitments are made to practices that go beyond March. The vaccination programme will take at least six months (and longer), so surely arrangements need to be put in place now that reflect that.

The ask of primary care is really significant at present, and practices up and down the country are going above and beyond to meet these challenges.  But practices remain independent businesses faced with unprecedented operational and financial upheaval, and my sense is more active support for practices needs to be provided to go alongside the demands being made of them.  Without it the current situation may not be sustainable.

My 2021 Prediction: How PCNs will change

As this is my last blog of 2020 (we are going to give you a two week break from the podcast and blog over Christmas!), I thought I would share what I foresee on the horizon for PCNs next year.  I am of course aware that predictions are a mug’s game (who could have predicted how this year would turn out?), but I always find it helpful to think through what might be coming up ahead.

My main prediction for 2021 is that there will be a move towards smaller PCNs.

Normally in the NHS, we like to start small and then merge organisations into bigger and bigger entities.  Those with longer memories will recall that multiple Primary Care Groups became a smaller number of Primary Care Trusts (PCTs), and the number of CCGs has been on the decline ever since their inception.

I suspect, however, the trend will be different for PCNs.

Currently, there are around 1,250 PCNs, and the “average” PCN is very close to the originally-envisaged upper limit of 50,000.  This means approximately half of the PCNs have population sizes in excess of the 50,000.  Why might that be?  Why have GP practices chosen to group into larger groupings than were expected?

My hypothesis is that the primary reason for this was because PCNs looked like a lot of work right from the outset, and it seemed sensible to group together so that work could be shared out between more practices, and the burden of additional work on anyone practice would be minimised.  The problem is we are now at a point where the resources and funding coming through PCNs is significant, and far outweighs anything that is coming through the core GP contract.  The ARRS in many PCNs will be funding not much shy of a million pounds’ worth of extra roles, and the extended access funding is also likely to be pushing £0.5 million for many PCNs.

What practices want is to feel the benefit of these resources.  The challenge of working with lots of other practices is these resources can feel distant from the practice, there can be lots of different ideas as to how these resources should be deployed, and it can be hard for any individual practice to exert the control it would like to over PCN decisions.

While at first it was helpful for practices to be distant from PCN decision making and to some extent be protected from the additional work, now that the resources are becoming very real many practices are finding the set up frustrating.  Cue conversations between smaller groups of often like-minded practices about what they think should be happening, and wouldn’t it be better if they were their own PCN?

It is a logical step.  Smaller groups of practices in PCNs can have really detailed conversations about how the totality of the resource they now have (existing practice resources and the additional PCN resources) can be combined to deliver maximum benefit to the practices and their patients, and ensure that all of the PCN requirements are met.

The artificial divide between PCN business and practice business does not actually serve either of those businesses, but is necessary when there are multiple practices operating together with relatively low levels of trust.  This barrier is removed when the PCN becomes smaller and the number of practices who have to work together is reduced.

The other factor at play is that it is very difficult to introduce new roles into general practice across large numbers of practices.  Those in the new roles need a home, and to be linked primarily with one practice, and receive all the support that comes with that.  PCN working across multiple practices does not allow that, whereas smaller PCNs can.  We are going to see significant turnover in the new roles next year, and they are likely to settle with those PCNs who are able to look after them.

There it is – more and smaller PCNs next year.  Have a great Christmas, I hope you have a chance to take some well-earned rest, and thank you for all your support this year.

3 Ways PCNs can make the most of their First Contact Physiotherapist

One of the most exciting of all the additional roles that are available to Primary Care Networks (PCNs) are First Contact Physiotherapists (FCPs).  This is because they have the potential to take on a significant amount of the general practice workload, and provide some much needed support to GP practices struggling to cope with the sheer volume of demand.  But what do PCNs need to do to ensure FCPs are able to fulfil this potential?

I spoke recently to Larry Koyama from the Chartered Society of Physiotherapy (CSP) on the podcast (you can listen to the full conversation here).  There is lots of great information on the CSP website about FCPs (e.g. here), but out of my conversation with Larry I took 3 key lessons for PCNs to make the most of their FCP:

  1. Ensure the Patient Sees the FCP First

Ok this might sound obvious to some, but there are some places where patients are being referred by the GPs to the FCP.  FCPs are (as described by Health Education England), “Regulated, advanced and autonomous health professionals trained to provide expert MSK assessment, diagnosis and first-line treatment, self-care advice and if required, appropriate onward referral”.  The role of FCPs is not to provide physiotherapy for those patients GPs assess as needing it; rather their role is to provide that initial assessment themselves.

The pathway PCNs need to create is for practice receptionists to be able to book patients directly into FCP appointments.  According to NHS England MSK conditions account for 30% of GP consultations in England, so the potential for workload to be diverted away from GPs via this pathway is huge.

  1. Base the FCP at a Single Site

The default guiding principle for GP practices working together is often equity.  Whatever service or scheme is being put in place GP leaders often have to work hard to ensure it is seen as equitable by all of the practices involved.  What this in turn often translates to when it comes to the PCN additional roles is they are split between all the member practices, so they might be at practice A on a Monday, practice B on a Tuesday, practice C on a Wednesday etc.

The problem with this approach is that, while it may well be equitable for the GP practices and their patients, it makes it very difficult for the new roles to feel they really belong anywhere.  Instead they are treated as visiting clinicians by every practice, and they never feel at home.  And when staff feel they do not belong, they do not end up staying very long.

On top of that, FCPs are new roles into general practice.  It is already difficult for the new starters to try and adapt to the general practice environment.  This sense of overwhelm the new recruits feel is exacerbated when they are have to get used to 5 or 6 different GP practices all at the same time.

A better model for PCNs is to establish a “host” practice for the FCP service, and set up a system whereby each practice can book appointments with the FCP for their patients.  It may be more work for the PCN leaders, it may be less popular with the member practices (less equity), but it will make it as easy as possible for the FCP to feel at home in the PCN, to feel supported, and to make the new way of working as effective as it can be for the practices.

  1. Link the FCP into the wider MSK system

Larry Koyama reported in our conversation that the CSP had looked at all the employment options for FCPs (including individual GP practices and PCNs) and they recommend that existing providers of NHS physiotherapy services employ FCPs.  This means they think that the best employer is actually the local community or acute trust.  The rationale is that it helps to embed and integrate FCPs across the MSK pathway (where they can access training and peer support), and the provider can ensure service consistency and staff continuity.

Now as well as equity, GPs prefer direct control, and I suspect few PCNs are minded to buy in their FCP service from the local trust.  However, what PCNs can do is make sure that professional training and development, as well as mentoring and peer support, is provided by the existing local provider.  This will ensure their FCP is not isolated, as well as linking them in to the wider local MSK system.

 

This year PCNs are only able to employ one FCP this year, but that number will go up next year.  By working hard now to support the FCPs they do have, PCNs will be in a great place to attract more FCPs in future and make the most of all they have to offer.

What Does the End of CCGs mean for General Practice and PCNs?

Last week NHS England published a paper in which it backed legislation to abolish Clinical Commissioning Groups (CCGs) by April 2022.  The aim is to replace them by giving the newly developing Integrated Care Systems statutory status.  What will these changes mean for general practice, and in particular for PCNs?

When they were established much of the rhetoric around CCGs was about putting NHS money in the hands of GPs, who know their patient populations and their needs best.  Whilst an attractive idea, the reality right from the outset was close control of CCGs by NHS England with very little room for GPs within CCGs to actively change the flow of NHS money.  Whatever else it might signal, the end of CCGs does not feel like it will be a loss of influence for GPs, because it is not clear that CCGs really ever had any.

NHS England’s paper is significant because it not only heralds the end of CCGs, but also the end of the purchaser provider split in the NHS.  This split was created by the last Thatcher government in the early 1990s in an attempt to create an internal market within the NHS.  Hospitals became provider Trusts, money to purchase care was given to Health Authorities, and GP fundholding was the first iteration of GPs being involved as the “commissioners” of healthcare.

What this paper does is (in effect) recommend the split (which has been largely ignored since the publication of the 5 Year Forward View anyway) is finally put out of its misery.  It is fair to say it was an experiment that has not worked.  At 30 years it is probably also fair to say it was an experiment that was allowed to go on for far too long.

What does this mean for general practice and PCNs?  Integrated care systems (ICSs) are to become statutory bodies, and general practice is represented on ICSs by PCNs.  Indeed, PCNs were created to represent local populations of 30-50,000 within ICSs, and ensure care is organised across agencies around the needs of those local populations.  It means the role of PCNs will become even more important.

Where in the internal market the commissioning organisation was expected to exert control over the delivery of local care via the use of contracts with provider organisations, within the new system the provider organisations are expected to work together and make sensible decisions as to how to use their resources to improve outcomes.

I can almost feel your scepticism as you read these words as to whether the new system will make things any better.  What the internal market has done through its attempt to create internal competition within the NHS is not to improve efficiency (as intended) but instead breed huge mistrust between different provider organisations.  It is going to take time for these organisations to get used to the new environment and learn to trust each other.

The real opportunity for the new integrated care system to work is only (in the short to medium term at least) at a local level.  Where relationships are between individuals trust can develop and mature quickly.  Where relationships are between organisations, with years of bad blood to overcome, trust will take much longer to build.  Front line clinical teams talking to front line clinical teams and working out sensible ways of doing things is how integrated care can make a difference that the internal market never could.

The changes that are coming represent an opportunity for general practice and PCNs, but they will need to take action to ensure they can make the most of it.  By April 2022 PCNs will be nearly 3 years old, and by then they need to be firmly established, have built some delivery capacity and capability, and have developed strong working relationships with local partners.  The challenge for PCNs and GP leaders in the meantime is to ensure that as ICSs develop primacy is given to making and supporting change at a local level, and that decision making doesn’t drift into large regional areas divorced from local teams.

Working Together: Covid-19 Vaccinations

It has been a stressful few weeks for many practices.  Not only did practices find out via the BBC that flu vaccinations for the over 50s are to commence from December 1st, they also had to agree with their neighbouring practices which sites are to be used for the delivery of the Covid-19 vaccine.

Working together is not easy.  Trust is hard to build between practices, and despite the progress made in recent months, agreeing a single site for Covid-19 vaccinations across PCNs within a week was always going to be challenge.

At the root of this challenge is the money at stake.  If the average practice has 8,000 patients, and we conservatively estimate that only half of these will receive the vaccine, then that is 4,000 patients x2 shots each x £12.58 a shot.  Which equals over a £100,000 per practice.  That kind of money will always create tension, but especially in a year like this when practices are under so much financial pressure.

Most practices would have preferred to deliver the Covid-19 vaccine in the same way that they deliver the flu vaccine to their patients – in their own practices with their own staff.  But the nature of this vaccine (it arrives in batches of 975, has a shelf life of only 5 days, is difficult to transport and wastage is not an option) means that it simply is not possible at this point in time.

The logistics are not the only reason it makes sense for practices to work together to deliver this vaccine.  Practices already have to deliver the flu vaccine to a huge new cohort at the same time as the Covid-19 vaccine becomes available.  The ask of practices already during this second peak of the pandemic is to manage the new virus on top of everything else that practices have to do.  At the same time as winter properly kicks in.  Individual practices simply do not have the spare capacity.

While the workload is growing, the workforce is much less resilient.  Everyday different practices are faced with the challenge of huge swathes of staff either sick or needing to isolate.  Individual practices cannot be sure they will be able to keep normal services running, let alone an additional vaccination service that requires 975 injections within a 5 day period.

Delivering this vaccine also requires a level of management capacity not present in the vast majority of individual practices.  We know the logistics are extremely challenging (think enabling national and local booking, cold chains, training staff, organising volunteers, working with other agencies on communication messages, managing the IT, without even getting into the reporting requirements that will inevitably be necessary).   It is not realistic to think a practice manager can do all this in their spare time.

The financial efficiencies are potentially greater working together.  A well run single site operating with a clear set of processes and flows can minimise the costs by maximising the numbers running receiving the vaccination each hour, and by working effectively with volunteers and partner agencies.

Many practices dislike working together, because it is difficult and requires a ceding of control.  But if there was ever a set of circumstances where it makes sense for practices to work together this is it.  That does not make it easy to achieve, or change the local politics or difficult relationships, but nonetheless it is an opportunity.

The vaccination programme has huge societal implications, and is a massive opportunity for general practice to be a key part of taking this country out of the situation it is currently in, but my one piece of advice to those trying to make this joint working happen is not to ignore the money.  Whether it is what is being talked about or not by practices, it is an issue that needs to be explicitly addressed.  Be clear how will the money flow, how it will be transparent, and how it will be fair.  It might not be the most important, but it is certainly an essential step to making the joint delivery of the Covid-19 vaccine by general practice a success.

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