Preparing for What is Next for General Practice

We enter 2024 without a clear steer as to what is coming next for general practice.  We know the existing 5 year contract, the one that created and developed PCNs, expires at the end of March, but what we still don’t know is what will be replacing it.  Faced with such uncertainty, how do practices and PCNs prepare?

A key part of getting ready is being able to respond quickly to any new changes that are announced.  NHS England is well known for delaying the production of guidance and then expecting general practice to respond within very short timescales to what are often major changes with far-reaching consequences, e.g. signing up to PCNs or establishing a Clinical Commissioning Group.

There are, however, a couple of things that can assist with this type of rapid decision making.  One is to read the detail of what is being proposed.  I am always surprised whenever I talk to groups of GPs how few actually read the documents in question.  While the documents are generally (deliberately?) inaccessible, relying solely on the interpretation of others can lead to skewed views about what is actually being put forward.

When digesting the new proposals the main questions to consider are what is the detail of what is being proposed, what will the impact of such changes be (on the practice, on the PCN), along with what the big picture implications of the changes are.  We might not have liked the details of the PCN proposals but the big picture implication was always that this was going to be the only way the practice could access new resources in the foreseeable future.

As a sidenote, a good preparation for what might be coming would be to read the Fuller Stocktake report.  This has become the de facto general practice strategy document (despite it being a report on integrating general practice with the rest of the system, but let’s not get into that again), and the author has since been appointed the National Primary Care Medical Director at NHS England.  Last year’s contractual changes around access were signposted in the Fuller Report, and it would be a surprise if whatever new emerges has not at least been mentioned in this document.

For an even more thorough preparation read the NHS Confederation’s document entitled, “Supporting General Practice At Scale: Fit for 2024/25 and beyond”.  In it they have, “identified a set of tangible recommendations for the upcoming GP and primary care network (PCN) contracts for 2024/25”, and whilst we would not be expecting the NHS Confederation to be determining the future of general practice, I explain why the document is important here.

The second action that can help prepare for what is coming is to find out from those people already doing the type of thing that is being suggested what the reality is actually like.  Unless the new proposals are one man’s crackpot scheme (CCGs may fall into that category) then there is normally always a predecessor, like the primary care homes that preceded PCNs.  Learning from the real life experiences of others can provide valuable clues to identifying the best way forward for ourselves.

Of course this requires the details to be published, but again there are emerging examples of some of the things included in the Fuller Report (like Integrated Neighbourhood Teams) developing across the country.

The good news is that help with all of this is at hand.  For the last two years I have been working alongside eGP Learning GPs Dr Hussain Gandhi and Dr Andy Foster and PCN expert Tara Humphrey in delivering PCN Plus, a training and support programme for PCN leaders.  Together, we are putting on a conference on Wednesday April 17th in Nottingham which is free for all practice and PCN staff to attend, when we will be both giving our take on what is coming (we think that even NHS England will have published the plan for 2024/2025 by April!), and be showcasing examples from those already further down the track.

If you want to make sure that you are ready for next year when the time comes then you can sign up for our free conference here (places are available on a first come first served basis) – I look forward to seeing you there!

Is Nationalisation of General Practice Inevitable?

The new NHS obsession is integration.  How can we join everything up so that it better meets the needs of patients?  But could this obsession spell the end of the independent contractor model for general practice?

The shift to integrated care systems is not helping general practice.  The internal market was the prevailing system in the NHS from 1991 when it was first introduced, right through until 2019 when the Long Term Plan was published.  Technically it continued until the new legislation was enacted last year, but to all intents and purposes we have been working under the new system for the last 4 years.

While the internal market was in place the system wanted to find a way to make general practice the “purchaser”.  Numerous different mechanisms to make this happen were attempted, starting with GP fundholding (remember that?) back in the 1990s, right through Primary Care Groups, practice based commissioning and then finally Clinical Commissioning Groups.

But the shift to Integrated Care Systems has stopped all of that. The strategic question the system is trying to answer is no longer how do we make general practice effective purchasers.  Instead the question now is how do we integrate general practice with the rest of the system.

The NHS Long Term Plan proudly states as its number one action in chapter one:

We will boost ‘out of hospital’ care, and finally dissolve the historic divide between primary and community health care

The problem with general practice (according to the system) is that it is too separate, too independent and not linked up enough with community and hospital services.

Plan number one to tackle this problem was the introduction of Primary Care Networks (PCNs).  The NHS Long Term Plan, the first place the idea of PCNs appeared, introduced them like this,

GP practices – typically covering 30-50,000 people – will be funded to work together to deal with pressures in primary care and extend the range of convenient local services, creating genuinely integrated teams of GPs, community health and social care staff”

I sometimes wonder if the first part of that description (“to deal with the pressures in primary care”) has been forgotten, but that aside it is clear the intention of PCNs is as an enabler of integration.  The original PCN DES stated that after one year a requirement to include collaboration with non-GP providers would be added to PCNs, but then Covid came and this never happened.  Instead the Fuller report (which as you recall was entitled, “Next Steps for Integrating Primary Care”, another clear pointer to the goal the policy makers are now trying to achieve) introduced the idea of Integrated Neighbourhood Teams, as the new souped-up PCN model to enable integration in a way that PCNs so far have not.

But will networks and neighbourhoods succeed in the goal of integrating general practice with the rest of the NHS?  If they don’t then the default is most likely a structural solution.  The structural solution would be to nationalise general practice and make it part of the NHS.  Then the integration box could be considered ticked.

This is why politicians on both sides of the political divide in recent years have suddenly started talking about the end of the independent contractor model.  Sajid Javid when he was Secretary of State got the ball rolling when he claimed in a Times article that nationalising general practice was a way to reduce hospital admissions.  Then earlier this year Keir Starmer said the GP partnership model was “coming to the end of its natural life”.  They, along with certain NHS leaders, are attracted to structural integration solutions because they are clear and can be imposed, even if they do nothing to develop the relationships that are required to make integration effective.

The last we heard there was not going to be any forced nationalisation of general practice.  But the question of how to integrate general practice remains uppermost in the minds of policy makers, and unless PCNs and integrated neighbourhood teams start making more progress soon a heavier push for general practice to be made a full part of the NHS seems inevitable.

5 Key Relationships for PCNs to Review

2024 is going to be a challenging one for PCNs.  The 5 year contract completes at the end of March next year, and while we know PCNs are to continue the pressure upon them is likely to be greater than ever.  Making sure the relationships they have in place now are where they need to be should be a priority for the coming months.  Here are 5 key relationships for PCNs to review.

  1. PCNs and their member practices

Over a quarter of all resources coming in to general practice now come via PCNs.  With all the wage and inflationary cost pressures the future of practices depends on PCNs more than at any point previously, and as we move forward this will become more not less important.  As a result, relationships can go two ways.  Either practices can start fighting with each other and the PCN leadership in a desperate bid to secure the resources they need, or practices can work together and attempt to make the most of the opportunity the PCN presents.

Practices within a PCN can ill afford to be at each other’s throats.  PCNs will increasingly have to take on the role of representing their practices in system discussions.  Rightly or wrongly, more and more the system is looking to PCNs as the unit of general practice that it wants to deal with.  Obtaining the best possible outcomes will require the practices within each PCN to be working together.

  1. PCNs and their local federation

I understand that not every area has a federation in place, but for those who do they could be a really important asset in the coming years.  The Fuller Report has pointed to the infrastructure underpinning PCNs and Integrated Neighbourhood Teams needing to be scaled up to be of the quality required in terms of HR, estates, finance and technology.  The local federation could be the provider of this infrastructure and the enabler of general practice controlling its own destiny.

The alternative is that the support for the PCN will be provided in future by one of the local NHS trusts.  With what I would euphemistically call “structural integration solutions” being very much on the agenda for general practice at the moment (i.e. making practices part of NHS trusts), then this would be a very risky road to travel down for those committed to a future for independent general practice.

  1. PCNs and the other local PCNs

It is hard enough for the practices in a PCN to all get along, never mind all the PCNs in a local area!  But the reality is that moves are afoot to shift more and more decision making about general practice, and potentially resources, from a national to a local level.  When this happens general practice in a local area needs to have influence and be able to speak with a united voice to ensure that any deals that are made locally serve the best interests of the practices and their patients.

But this requires PCNs to be able to work effectively with each other.  There need to be trusting relationships in place, an ability to represent each other in system discussions, and a way of making decisions together.  This takes time, and so time is running out to get this to where it needs to be.

  1. PCNs and the local system primary care group

System primary care groups are odd creations.  In many places they have been formed by the system rather than by general practice, the agendas are set by the system teams, and the membership is generally appointed rather than representative.  Yet the likelihood is that these groups will be the place where decisions about general practice  are made, which could have huge resource, workload and strategic implications for PCNs and practices in future.  Now is the time for PCNs to review whether these groups are working, whether their voice is really being heard, and to push for changes so that these groups are fit for purpose moving forward.

  1. PCNs and local community providers

For the last 18 months the spectre of integrated neighbourhood teams has loomed over PCNs, with the Fuller report saying that these are what PCNs would ‘evolve’ into.  But more and more it is becoming clear that PCNs will be the general practice partner within these new teams, rather than them being a new future for PCNs themselves.  That said, the system focus remains very heavily on bringing primary and community care closer together, and so PCNs getting on the front foot in building these relationships will put them in the best possible place as these new teams develop.

The Changing Role of the PCN Clinical Director

Four and half years into PCNs and it is no surprise that in that time things have not stayed the same.  One thing that has changed more than anything is the role of the PCN Clinical Director.  But has it evolved far enough?  What does the role need to be going forward to ensure future success?

When PCNs first started the role of the PCN Clinical Director was very much about start up, about getting the practices engaged in the PCN and enabling the PCN to take its first steps as a collective unit.  A whole raft of seemingly endless recruitments followed, liberally interspersed with responding to a global pandemic, setting up a vaccination programme, and an ever-increasing set of demands upon these fledgling organisations.

For much of that time the focus of the PCN Clinical Director out of necessity had to be internal.  In many PCNs no other capacity existed, so for anything to get done it was down to the PCN Clinical Director to do it.  But over time, gradually, this has changed.  PCN managers have been appointed, and more recently these have been supplemented by more senior Digital and Transformation Leads.  Throw in some administrative support and some PCNs can now even lay claim to having management teams in place.

With the rapid expansion of the additional roles many PCNs have introduced clinical leads, e.g. to look after the supervision, training and development of the clinical pharmacists or the physiotherapists or the social prescribing link workers, or to lead on some of the many operational components of the PCN DES such as the IIF or the new access requirements.  Meanwhile the role of the PCN Clinical Director has been evolving into one supporting this range of management and clinical leaders, as opposed to one directly delivering the work.

Some PCNs are much further down this road than others, but it is an important journey to take.  Looking into the future what practices will need from their PCN Clinical Director is a much clearer external focus.

The future direction for PCNs is to be part of Integrated Neighbourhood Teams (INTs).  As these have started to develop we can see that the PCN is the unit of general practice operating within these local teams.  A key part of these being successful, or making any form of difference, will be the relationships between the different organisations that are involved.  For PCNs this means that someone has to have the time to invest in building these external relationships, and that in most instances means the PCN Clinical Director.

At the same time the ability of general practice to operate effectively as a collective unit within a local area is becoming more important than ever.  Increasingly we are seeing decision making about general practice being shifted from a primarily national locus to a local one.  It is highly likely that in the coming months much more of the funding for general practice and for PCNs will come through local systems.  PCNs (like it or not) are the main units of general practice within an integrated care system, and so the voice and influence of the PCN Clinical Directors will be hugely important.

PCN Clinical Directors need to have the capacity to build the relationships with external organisations and wider local general practice to be effective going forward.  They will not be able to do this if they are stuck managing the day to day operations of the PCN.  While many have started the journey of releasing the capacity of their CD, for many there is still a long way to go.  Getting as far as possible by March next year is likely to be of critical importance both for the future success of the PCN and of local general practice.

What if the PCN DES was commissioned locally?

One of the potential scenarios for next year is that the funding for the PCN DES will be shifted from the national contract and given to local Integrated Care Boards (ICBs) to commission locally.  What impact would this have?

I should start by saying I don’t know what is going to happen next year, although as I wrote last week we know more than we sometimes think we do.  I don’t have any inside track or knowledge beyond what anyone else has, but based on what we do know it is possible to hypothesise about what next year might bring.  So to be clear this is a thought experiment on what might happen, not a statement about what will happen.

We know the system is pushing for is greater local control of GP funding.  While there have been some ideas floated previously around QOF potentially being commissioned locally, it would seem to me that a much more likely target would be the PCN DES.  PCNs are the basic unit of integration for local systems, and as such it would actually be surprising if systems did not want more control over them.  PCN DES money is not technically core contract money (despite it now constituting more than a quarter of all funds coming into general practice), and so it may actually be easier to shift to local control than other parts of the contract.

What would happen if such a change was to occur?  The first thing we would see would be an increase in variation across the country.  The national contract brings a degree of standardisation which would be lost with such a shift.  We would most likely see some areas add additional local investment to the PCN DES pot to accelerate the local development of PCNs and the shift to neighbourhood working, while others would most likely view it as another source of funds that could be accessed to cut costs so that the system could get closer to its financial savings targets.

We would probably also see variation in how the PCN DES funding is treated.  Some ICBs would understand the funding to be primarily general practice funding, and be mindful of the role this funding plays in supporting the sustainability of general practice.  Others would see the funding as system funding for neighbourhoods, with general practice being only one part of what constitutes a neighbourhood.  One suspects in those areas it would not be long before the resources within the DES started to be shared across a wider group of providers.

Then there is the ‘infrastructure’ question posed by the Fuller Report.  The report stated that PCNs’ “lack of infrastructure and support has held them back from achieving more ambitious change”.  So where does this infrastructure come from?  According to the Fuller Report this would come from an at scale general practice provider or existing NHS Trust.  Would it be wholly unexpected, then, if ICBs then contracted the PCN DES money via one of these providers?

If you take into account the new provider selection regime, which is due to come in place in the new year (watch out for my forthcoming podcast with Ross Clark from Hempsons for more details on this), then actually making this happen would be relatively easy for ICBs.  Having PCNs being directly contracted by the local community or acute trust does provide the type of structural integration ‘solution’ that the NHS heavily favours.

It all feels like a high risk scenario for general practice.  While it may create local opportunities in some areas, it clearly comes with huge risks.  Of course it may not happen, but it is exactly because scenarios like this are not unrealistic that it is critical general practice in local areas work together to develop their local system voice and influence.  This way at least it is in a position to mitigate some of the bigger risks that such a change would cause.  Even if it does not happen next April the chances are high that this will come at some point, and so being prepared is essential.

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