Primary Care Networks: A Roadmap until the end of June

While many have sat back and breathed a collective sigh of relief that the 15th May deadline was met for the submission of the initial PCN returns, that was unfortunately only the start of the journey.  Some pretty formidable challenges lie ahead.

I am sure some PCNs have a clear plan and are meticulously ticking off actions and making sure everything is sorted as they get ready for the 1st July, when PCNs formally begin.  This is less for those PCNs, and more for the time poor and those who have that feeling there is something they should be doing but they are not sure exactly what! It also doesn’t cover everything you could be doing (if that’s what you need do watch out for Clare Allcock’s wonderful advice on how to accelerate collaborative working in next week’s podcast).  Rather this is designed to help you meet the minimum requirements.

Essentially, each PCN has to complete three key actions by 30th June:

  • Agree how extended hours will be provided at a rate of 30 additional minutes per 1,000 registered patients to all registered patients within the PCN.
  • Ensure appropriate data sharing agreements and, if required, data processing arrangements are in place, using the national template, to support the delivery of extended hours.
  • Ensure the network agreement is completed (including all seven schedules), and signed.

For the provision of extended hours, each PCN will need to know:

  • Does each member practice wish to undertake the delivery of extended hours for their practice population?
  • If any practice does not, is there another practice willing to take the delivery of these hours on?
  • If not, is there a third party who can deliver the services on behalf of the practices?

It is easiest if each practice does their own extended hours, next easiest if there is some sort of buddy arrangement between practices so that they can cover each other, and least easiest if you have to create some new model of joint working across practices.  That is not to say one model is better than the others, only which is easier in terms of the amount of work each will require in the month until the next submission is due.

Now you may be lucky and already have data sharing agreements in place between your practices.  If you don’t, then there is the promise from NHS England of a national template.  Unfortunately, the PCN frequently asked questions states that this is not yet available as it has to be agreed with the GPC.  Watch out for its publication, as you are not going to have long to turn it round and get it agreed by your member practices.

As for completing the network agreement, remember the starting point for each PCN is the mandatory network agreement (here).  This mandatory agreement cannot be altered.  However, there are 7 schedules where additional clauses can be added.  The template for completing the schedules can be accessed here.

I am not a lawyer, so this is not legal advice, but if you had to prioritise you could go with the suggested wording of the national agreement and not worry too much about schedule 2 (essentially this schedule is where you can make changes/additions to some of the mandatory network agreement), and for schedule 6 you could go with the suggested list of insolvency events (it is essentially a list of different events of insolvency that would enable members to take action under the clauses).  The difficult bits you would then have to sort out are:

  • The rest of schedule 1 (you have already done some of it) where you have to say how the meetings will take place, what is quorate, how you will make decisions etc etc
  • Schedule 3 where you outline everyone’s responsibilities in delivering extended hours
  • Schedule 4 where you have to outline all the network’s financial arrangements (how much money each practice is getting and who is going to pay it)
  • Schedule 5 where you set out the arrangements in the PCN for engaging or employing staff, including arrangements for employment liabilities
  • And schedule 7, which is essentially how you will work with any other organisation (e.g. a federation). Top tip here is get them to draft it for you, and then change their version, rather than starting with a blank piece of paper.

I don’t know how many meetings you are realistically going to have with your practices between now and the end of June, but if it isn’t many you may want to find someone to draft a starter for 10 for each of these schedules.  If you can agree 90% of them remotely, then you can use any valuable meeting time to focus on the hopefully small number of areas that are left.

And once you have done all that, you are probably going to need to get a lawyer to look over the final agreement with all its appendices before you can persuade your practices to sign it.   Remember the submission of the network agreement is due by 30th June which (inevitably) is a Sunday, which means the 28th June, which means there is only one month to go to get everything done.  No pressure!

What would be really helpful would be sharing across PCNs of good ideas for improving the agreement between practices, strong additions to the network agreement, and good wording for the schedules.  Anything we find along the way we will definitely pass on.

I hope that is useful.  If you have any advice for over-stretched incoming PCN leaders that I have missed please do get in touch to share.  Good luck all!

Guest Blog – Tara Humphrey – Introducing New Roles

This week we are delighted to feature a useful guide from our old friend Tara Humphrey, founder of THC Primary Care. Tara appears on this week’s podcast talking about the introduction of new roles to Primary Care Networks. You can find that here.  In support of that podcast Tara has provided us with a written guide to the practical stuff you’ll need to know and you can download that by clicking on the link below:

Tara New Roles

PCN Deadline Day: 8 Lessons we have learnt so far

Primary Care Network submission day has arrived!  3½ months have passed since Primary Care Networks were formally announced as part of the new GP contract for 2019.  What have we learnt in the intervening period?  I would suggest there are (at least) 8 key lessons.

  1. PCNs represent the biggest change for general practice in a generation. While PCNs may have started life as only one part of the package that was the 2019/20 GP contract, it has become clear they represent a much more fundamental change for general practice.  Funding flows into the profession are set to shift from being primarily at an individual practice level, to being primarily at a PCN level.  The fates of GP practices within a PCN are set to become inextricably intertwined.
  2. 15th May was an ambitious deadline for PCN submissions. The initial expectation was practices would have their network agreements in place by today, but as the complexity of that particular task became clear the deadline for the full agreement was relaxed to the end of June.  Practices choosing whom to get into bed with has taken most of the last few months (and some may still not be there yet!), and the challenge of defining the nature of the agreement between them still lies ahead.
  3. The lawyers are coming. What wasn’t clear at the outset was how defined the nature of the network agreements between the practices needed to be.  NHS England has produced a “legally binding” mandatory network agreement for all practices to sign up to, but the meat of this agreement has been left to schedules that need to be developed and agreed locally, which will inevitably require lawyers.  It will be hard to keep the focus on trust and building relationships, which is widely agreed to be the most important foundation for a successful network, once the lawyers are in.
  4. Focus has shifted away from the sustainability of core general practice. In the context of the new GP contract, PCNs were heralded as the mechanism for enabling new funding and resources to flow into general practice.  But on top of the legal fees, each new role requires practices to dip into their pockets to finance the unfunded elements, and the funding for extended hours has been cut.  The talk surrounding PCNs has quickly moved towards “system integration” and equally quickly away from the sustainability of PCN member practices.
  5. The gap in funding for new roles is high risk. As practices have picked through the funding of the new roles, they have found that the headline 70% is an optimistic assessment of the national contribution.  This contribution is fixed regardless of the local market for the roles, or the package the network ultimately has to offer.  Financial liability for the new roles, for example in the case of redundancy, also sits with the practices in the network.  Whether all networks take up the offer of the new roles remains to be seen, but it appears increasingly likely at least some will not.
  6. PCNs represent a shift in system GP leadership. CCGs always had the problem that they represented their population not their practices, despite being membership organisations.  The introduction of PCNs coincides with a 20% cut to the management costs of CCGs and a likely move to a wave of mergers, making CCGs yet more distant from local areas.  At the same time PCNs will each hold seats on the integrated care system boards, as the means of providing “full engagement with primary care” (Long term Plan 1.52).  There is a clear shift of power in motion from CCG GP leaders to PCN Clinical Directors.
  7. The role of Federations is uncertain. Federations were conspicuous by their absence from the Long Term Plan and the new GP contract, and it is clear that PCNs are flavour of the month.  It remains to be seen the extent to which PCNs will work together effectively through federations, or whether each PCN will plough its own furrow.
  8. Expectations of PCNs at practice and system level are very different. There are grand plans for PCNs in the Long Term Plan, as the focus of developing place-based care and integrating services around local communities.  But the challenges facing front line GP practices have not gone away, as the recent Panorama programme highlighted.  Practices need PCNs to first support and enable their sustainability, whereas the system expects them to first prioritise delivery of their own plans.  How that tension plays out remains to be seen.

We are still at the very outset of PCNs.  Establishing them may have been the easy step, compared to some of the questions that remain unanswered and the challenges that lie ahead.

Will the PCN Voice really count?

The Long Term Plan published in January of this year said, “Every integrated care system will have… full engagement with primary care, including through a named accountable Clinical Director of each primary care network.” (1.52)

The GP Partnership Review, published shortly afterwards, said, “Working at scale, for example through Primary Care Networks, has the potential to improve and support general practice influence at a system level.” (p35)

The question is will the establishment of PCNs and the new Clinical Directors really mean that general practice has a voice, and be able to influence outcomes (and the flow of resources) at a system level?  You could argue the establishment of Clinical Commissioning Groups as statutory bodies was supposed to achieve just that, yet they have presided over one of the worst periods of under investment into general practice in NHS history.  Clearly setting up an infrastructure doesn’t of itself necessarily translate into a bigger voice.

Of course, some might argue, CCGs were commissioning organisations and PCNs are provider organisations, so this time it is different.  It is hard for the average GP not to be cynical about yet another promise that “this time it is different”, after so many previous identical promises failed to deliver.

We are heading in the direction of c1000 Primary Care Networks (PCNs) across England.  There are 44 STPs, so we are looking at c20 PCN Clinical Directors per STP.  Even though this is hugely more manageable for system leaders than 7,000 GP practices (c150 per STP), it is difficult to overestimate the challenge for each one of those 20 Clinical Directors trying to influence for their particular PCN.

In the model of “place-based care” (NHS-talk for providers from across health and social care working together at a PCN level), you could argue PCN Clinical Directors will be leading and shaping the integration of services locally.  However, this also depends on whether the reality of how place-based care works is bottom-up (decisions made by local teams), or top down (decisions made at STP level, and PCN leaders asked to implement them).  This in turn will depend on how influential the PCN leaders are at STP level.

The challenge facing the new Clinical Directors of PCNs is formidable.  They have to introduce joint working across GP practices that have never really worked together previously, and manage all the inevitable internal disputes and conflicts that will arise, before they can even start thinking about how they will work with local partners, and how they will create a strong voice for local general practice.

My sense, however, is that it is important to start as you mean to go on.  While the odds may initially be stacked against PCN Clinical Directors, the reality is the system needs them more than they need the system.  There is the opportunity to influence, but only if it is seized and taken from the start.  It is not going to come on a plate, and the new leaders of primary care will need to work hard to establish their voice.  Done badly, the voice will not be strong.  But done well, I think there are many gains to be had for PCNs, their practices, and their local populations.

It is with this in mind that here at Ockham Healthcare we have created a brand new (free) guide for PCN CDs on how to establish an effective voice.  It includes 10 practical steps PCN leaders can take to make their voice effective.  If you are already on Ockham Healthcare subscriber you will receive the guide free via our weekly newsletter on the 9th May.  If you are not a subscriber just sign up here (for free) and we will email you a copy.  I hope you find it useful, and good luck with finding your voice.

Guest Blog – The new Primary Care Network Agreement

This week our old friend John Tacchi returns with a guest blog on the newly published Primary Care Network agreement. A vital set of documents which will dictate the shape of PCNs for years to come.  John critiques the agreement…and doesn’t pull his punches.

NHS England has released the mandatory Network Agreement which all PCNs will have to sign. It consists of two documents, the agreement and the schedules. Given the importance of this document (bear in mind that in future, payments to GPs will increasingly be made to PCNs and less to individual practices), it is a bit thin. Terribly thin in fact. Rather than pick it apart, let us instead consider what it actually says and what is left in the hands of GPs to sort out for themselves.

The Agreement

This is the document that all members of the PCN must sign. It is categorically stated as ‘legally binding’ and so will govern the future relationship of the practices which make up the PCN and govern the flow of money. There are 106 clauses and you would be forgiven for thinking that this is where the ‘meat’ is. These cover general obligations and patient involvement, financial arrangements, workforce, information sharing and confidentiality, conflicts of interest, meeting format (governance generally), joining and leaving the PCN, duration and variation, termination, dispute resolution and ‘events outside our control’.

Except they don’t. The clauses in the agreement all refer to the schedules for greater detail. The schedules document is, however, a series of blanks, leaving PCN members to fill in as necessary. This is not particularly helpful and leaves GPs to sort out a host of vital issues themselves. The top 5 are:

Financial arrangements

There are so many issues under this heading. If one practice in the PCN is designated to receive PCN payments, how will it pay what is owing to other practices? When? On what basis (i.e. what happens if another practice does not provide the PCN services required)? How will be accounted for? What happens when there are other organisations other than practices involved? What about possible insolvency of a practice; how will this impact the PCN? What about intellectual property rights of individual practices/partnerships? How will these be protected? Can individual partners of member practices be sued for the liabilities of the PCN? No detail. Not good.

Workforce

Given the fact that money is being made available for additional roles (but not at 100% reimbursement), who will employ them? If the practice that is the designated fund-holder does, is it aware of the implications from an HR perspective? If another organisation employs them (i.e. a new company), there may be VAT issues. This has the potential to create horrendous problems.

Governance

How will the PCN decide on pressing issues? It will need to have some a ‘board’ of some kind and who will be on it? What will the role of Clinical Director be? Will representatives of the ‘board’ have authority to bind individual partnerships? What is the legal status of decisions made? What about liability issues? How will a PCN vary the agreement if it needs to? Many, many open questions.

Joining and leaving the PCN

This is probably the most glaring ‘omission’ (given the schedule simply says ‘fill in the blanks’). How do practices leave and are they even able to do so? Can a PCN expel a member practice? If so, how? If a PCN expels a practice, what becomes of the patient list? How will they still receive PCN services?

Dispute resolution

What happens if things go wrong? What is the legal status of member practices within the PCN? Who will act as arbiter in the event of a dispute?

Timing is obviously an issue. The network agreement and all its schedules must be signed by all member practices by June 30th.  This is not very far away! The current version does at least say that the agreement can be varied from time to time, but this first draft is so devoid of detail that PCN members really must get specialist advice before signing anything. Lawyers are expensive and it is only the national firms that have the breadth of experience to give a detailed view. They are very expensive. GP’s need specialist advice on this vital issue. And fast!

John Tacchi

Tanza Partners

www.tanza.co.uk

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