How can Federations help Primary Care Networks?

Amongst all the furore that primary care networks are creating it is easy to lose sight of GP federations. The role of federations in the new world of primary care networks is unclear and not prescribed. So do they really have a future? If they do, what will it be? This week, I explore how federations could help the nascent primary care networks meet four of the biggest challenges they face.

Challenge 1: Managing the new clinical staff and the associated liability

By 2024 a typical (50,000 population) primary care network will have 5 clinical pharmacists, 3 social prescribers, 3 first contact physiotherapists, 2 physician associates and 1 community paramedic. That is a lot of staff. Who is going to manage the employment risk (and associated liability) for these staff? Some will arrive with considerable amounts of NHS service, making the potential employment liability very high.

Federations established as limited liability vehicles can not only take this risk away from GP partners, but can also add real value to the recruitment, management and development of these staff. When multiple networks are seeking to recruit from this limited pool of new staff, why will they select one area over another? If a federation can offer peer support, professional development, and (probably most importantly) structured support for both practices and staff in the implementation of these new roles, they will make their area more attractive to these staff, as well as ensuring the networks gain the greatest possible benefit from them. It is hard to overemphasise the importance of change management support to go alongside the recruitment of these new roles.

Challenge 2: Maximising the available financial resources and minimising the financial risk to practices

The new GP contract suggests that a typical network will have funding for additional role reimbursement of £726,000 by 2023/24. At 70% this creates a potential cost pressure for networks of up to £311,000. As a side note it has been suggested (e.g. in the BMA primary care handbook) that the £1.50 management allowance could be used to offset this, but the total management allowance for a 50,000 network is £75,000 – well short of the total amount potentially required.

It is on the finance side and meeting the “30% challenge” that federations can really come into their own. Federations can:

• Limit liabilities through an incorporated structure
• Attract further investment. Many CCGs and local integrated systems will want to invest in general practice, but will want to do it at a scale that maps to boroughs or historic commissioning areas, and federations providing an infrastructure across multiple networks will be an attractive vehicle for them to do so.
• Make the £1.50 management allowance go further. A typical network can’t hope to include delivery support, administrative support, communications and engagement, HR, financial support and leadership support with £75,000. But multiple networks working together could easily do this.
• Create other economies of scale. The £6 per head for extended access is a great example of a resource that if used collectively across a wider area through a federation could generate a significant return to constituent networks.
• Establish strong financial governance. A small but effective finance team within a federation can ensure financial risks are minimised, financial efficiencies are delivered (e.g. in relation to what funding is superannuable), and income opportunities are maximised.

Challenge 3: Ensuring delivery both across practices and with other organisations

Networks are not simply constructs that need to be created. There is a delivery expectation upon them, both across constituent practices and with local organisations. Five new network specifications kick in in April 2020, probably alongside the requirement to sort out extended access, plus any local enhanced serviced the CCG may want to add in to the mix. How will one network operating on its own get its head around all of the new delivery requirements? The nature of the new specifications mean it will not be as simple as passing them on to the member practices and simply asking each to do its share. New delivery models will need to be developed, agreed with practices and local organisations, and implemented.

It may be on the delivery requirements of networks that federations can add the most value. Resources can be dedicated to each of the network specifications, for example a clinical lead and a lead manager for each, who can negotiate with local practices, organisations and commissioners to create locally-tailored delivery models. Sharing resource and expertise in this way through a federation can reduce duplication and enhance local delivery.

Challenge 4: Meeting the leadership challenge of networks and creating a powerful local voice

Much is expected of the new “accountable” network Clinical Directors. They are to become the voice of the network in the plethora of integrated care meetings locally, as well as leading the development and delivery of new services, and sorting out any inter-practice issues – all in roughly one day a week. Nationally we have heard of a desire for new leaders to emerge from practices to take on these roles. These could be very challenging and isolating roles for potentially inexperienced leaders.

Networks operating together within a federation can do a number of things. They can provide leadership development. They can ensure the leaders work together to support each other, and share ideas, approaches and learning. The incessant representation requirements from the wider system can be prioritised and shared across the group. Equally, a strong collective voice for primary care and the area can be established through a federation (whereas multiple network voices, potentially contradicting each other, is likely to weaken the overall general practice system voice).
Primary care networks are not in competition with each other, and working together through a federation can help meet some of the major challenges they will inevitably face. It does of course rely on trust, and a belief that the federation will operate to serve and support the new networks. It may be that governance changes, such as ensuring there are at least a majority of network clinical leads on the federation board, are needed to establish the future role of the federation in support of networks. But however it is done, it does seem there could be a very important role for federations in support of general practice as we move into the new world of primary care networks.

The new BMA Primary Care Network Handbook

More information was recently published by the BMA on primary care networks.  You can read it here.  I would regard it as essential reading for all GPs and practices who are considering joining a network.   But at 30 pages it takes some working through, so for the time poor I have summarised below what it says about the questions not answered in the initial contract document.  The answers provided are essentially quotes from this new BMA handbook.

Can CCGs influence the shape of the new Primary Care Networks?

The only involvement of the CCG in this process should be when there are gaps in the total PCN coverage of their area. (the document’s highlighting, not mine)

The content of the network agreement is not within the remit of the CCG to challenge. As long as the practices have agreed, the CCG cannot refuse the DES based on its content.

What agreement is required between practices in a network by 15th May?

To be recognised as a PCN, individual GP practices will need to make a brief joint submission outlining the initial network agreement signed by all member practices.  This will specify how the member practices will handle network-specific issues such as:

  • decision making, governance and collaboration arrangements
  • arrangements regarding the delivery of different packages of care
  • the agreement for distribution of funding between the practices
  • arrangements regarding the employment of the expanded workforce
  • internal governance arrangements (appointment processes, decision making process, etc).

Who can be clinical director of a primary care network? Does it have to be a GP?

It is expected that the clinical director will be selected from the GPs of the practices within the network, but any appropriate clinically qualified individual may be appointed.

While there is no requirement for the clinical director to be appointed from within the network, we recommend that the first option should be to consider an appointment from within.

How will Primary Care Networks make decisions?

Each network is to have a governing/representative body.  This network “board” should operate as the network’s governing body, bringing all members together, overseeing joint decision making, the strategic direction of the network and the network’s funding/financial layout. It is also the body to which the clinical director would be directly accountable.

The network will need to decide:

  • what is within the remit of the clinical director to act executively, what needs to go back to the practice representatives
  • how the governing body makes decisions – does it require a simple majority, a conditional majority, unanimity, etc
  • how often the governing body should meet
  • how meetings are chaired (an elected chair, rotational chair, etc). As the clinical director will be accountable to the governing body, it may be better for the role to be excluded from chairing the governing body

What will the operating model of Primary Care Networks be?

Key issues to consider when establishing an operating model include employment liabilities, ability to offer NHS pension, and inadvertently attracting VAT charges.

5 potential operating models for networks:

  1. “Flat practice network” – practices work together and spread responsibilities and commitments, with one practice acting effectively as the network bank account.
  2. “Lead Provider” – a lead practice takes responsibility for engaging the workforce and entering into contracts
  3. “GP Federation/Provider Entity” – the provider entity is subcontracted to deliver services required by the DES and to employ the staff
  4. “Super-practice as a network” – a super-practice creates an internal ‘network’ amongst its constituent sites, with each ‘neighbourhood’ of practices operating as a mini network in themselves.  The super-practice would be the nominated payee and would then supply support and resources to its constituent neighbourhoods.
  5. “Non-GP provider employer models” – the non-GP provider is signed up to the network agreement, along with the GP practices. They provide network services and employ staff available under the DES on behalf of the network, as well as using their own staff to further enhance the network’s potential workforce.

All primary care networks will need management and administrative support structures.  Practices that form the network will also need to seek advice on any proposed legal agreements and financial matters, and will need to establish a regular meeting of their representatives to ensure that things are developing as planned.

What will Primary Care Networks actually do?

Networks will develop expanded practice-based and connected teams to deliver the provision of workload support of the member practices by:

  • working alongside the existing practice team and taking responsibility for some services of the member practices (to be decided by the network), focusing on extended-hours delivery in the first instance
  • restructuring some service delivery (to be decided by the network)
  • offering access to the extended PCN team (extending the workforce).

The funding currently associated with the Extended Hours DES will transfer (with the associated responsibilities) to the network. This will be provided as an entitlement to the network’s nominated bank account of £1.45 per patient. The network will decide how this funding is distributed in line with the provision of services required to fulfil the requirements of Extended Hours.

The £6 per patient that is currently provided for the Extended Access scheme will also transfer to the networks; the exact timing of this transfer will depend on the current arrangements in each area for the Extended Access scheme… The intention is to bring together extended hours and extended access activity to reduce fragmentation and confusion for practices and patients.

How will the funding for the new PCN workforce role work?  Will smaller networks receive (proportionally) more funding?

There will be funding for the clinical lead post for each network on a basis of 0.25 WTE per 50,000 patients, at national average GP salary (including on-costs) (of £137,516).

For the first year of the DES (2019/20), every network with a population of at least 30,000 can claim 70% funding as above for one additional WTE (whole time equivalent) clinical pharmacist and 100% funding for one additional WTE social prescribing link worker.

The level of funding available for a PCN will scale with its size. This will be especially true in future years when workforce funding switches from direct reimbursement to a capitated payment, based on the population size of the PCN.

Over the coming years…the workforce reimbursement system will be altered so that it is linked to the patient population of the PCN.

The network will need to provide a monthly invoice with evidence of costs to its CCG, and will be reimbursed the required amount up to the maximum reimbursement. The maximum reimbursable amount for each of these roles will be set at the weighted mid-point of the respective Agenda for Change salary band.

There are no mandated contractual terms for staff employed under the PCN DES.

Can the funding be used for additional staff practices have already employed?

Staff employed under the DES must be ‘additional’ to the existing workforce employed by the network’s member practices. This will be measured on a 2018/19 baseline established as of 31 March 2019…The only accepted exception will be those clinical pharmacists employed via either the national Clinical Pharmacist in General Practice scheme and Pharmacists in Care Homes scheme.

How are practices expected to fund the 30% staff costs (for roles where only 70% funding is provided)?

2 options:

  • Use the network payment (e. the £1.50 per head).
  • Practice-pooled funding (e. contribution from each practice)

Who will be responsible for distributing the network funding?

How funding could flow in a network – 4 examples:

  1. “Flat practice model” – expenses shared across member practices
  2. “Lead practice model” – a single practice takes sole responsibility
  3. “GP federation/provider entity” – the limited liability provider entity takes responsibility
  4. “Non-GP employer” – the non-GP healthcare provider takes responsibility

Can my CCG decide not to provide the required funding for networks?

Commissioners cannot remove or reduce the entitlements, but they can add to them.

Commissioners may choose to transfer, where appropriate, their locally commissioned services contracts to the network, rather than with individual providers.

Are Primary Care Networks just a precursor to general practice becoming part of Integrated Care Providers?

A more controversial model of integration, the ICP (Integrated Care Provider) has also been introduced by NHS England. ICPs involve merging multiple services into a single contract, held by a single provider. ICPs have been subject to controversy and the BMA has been clear that we oppose their introduction, as they increase the risk of privatisation and are incompatible with the independent contractor status of GPs.

How Much Governance is Enough for Primary Care Networks?

The relationship was over.  After a bright beginning things had slowly deteriorated, and now it was time to call it a day.  The problem was we had a house, a car, joint bank account, the works.  We were faced with a choice – get the lawyers in to fight it out, or sit down and work it out ourselves.

Would we have been better sorting out a legal contract at the beginning, so that in the event of this situation arising we would have had a framework to sort it out?

This is the question some practices facing the prospect of entering a Primary Care Network are asking themselves.  Two thirds of the promised new money for general practice is coming via these networks, and that may just be the start.  CCGs and STPs are likely to put nearly all future local enhanced services through these nascent networks.  The fates of each practice within a network will be intertwined.

With this in mind, the temptation is to establish some form of legal contract between the practices.  Yes there is going to be a model network contract, but is it going to be enough?  Networks are going to need every practice to pull their weight.  Would it be better to get them to sign up to both their commitments and, more importantly, the consequences if they don’t meet them?  Won’t that provide better protection for everyone?

Back to the end of the relationship.  We sat down and had the difficult conversation, and agreed who would be having what.  It felt like a better way to sort things out than paying expensive lawyers and asking them to decide.  We would have had to have the conversation anyway, but this way we had it face-to-face rather than through our legal representatives.  I don’t think an upfront legal agreement would have done anything other than breed mistrust from the very beginning and increase the likelihood of legal fees down the line.

If a practice in a network doesn’t pull its weight, doesn’t fulfil its commitments, or doesn’t do what it is supposed to do, all of the practices will lose out.  Stronger legal agreements won’t prevent the need to have the difficult conversation.  Better to focus on the work needed to avoid this situation in the first place.

Three things feel more important than investing in lawyers for practices at this stage:

  1. Build positive relationships. Develop enough trust between practices to be able to have the “difficult” conversation without getting the lawyers (or the CCG, or NHS England, or the LMC etc) in.  Time invested in relationships before these conversations are required will repay itself over and over if it means practices in a network can work through their own challenges and issues internally.
  2. Appoint the right GP network leader. Brokering these conversations is likely to fall to the appointed GP lead of the network.  Building bridges between the practices may well be the key challenge of these new leadership roles, and be much more difficult than the external facing requirements.  Appointing someone trusted by all of the practices will be key to future success.
  3. Get the size of the network right. Smaller may be better.  There has been an initial reluctance in certain quarters to move from pre-existing localities and groups of 70 or 100 or even 150 thousand populations into the new 30-50,000 limits.  There is a sense of safety in numbers in the larger groupings.  But the point of the new size is that it is small enough for everyone to know everyone.  At this size, building trust across everyone is more possible, and the leadership challenge less impossible.

One of the key strengths of general practice has been the family feel of the practices, and the close relationships between staff and with patients.  This is a strength practices should aim to build on as they move into networks, rather than abandoning personal relationships in favour of legal frameworks as a way of reducing risk.  Involving lawyers might feel like it is adding a layer of protection, but the reality is the success of the network will be based on the strength of the relationships, the quality of the leadership, and the ability to have the difficult conversations when they are needed.

What do Primary Care Networks Have to Do?

It is easy to get lost right now in the immediate challenge of identifying practices to be in a network with, persuading someone to be the ‘accountable clinical director’, and deciding who should hold the network bank account.  But to get these short term decisions right it is worth spending some time reflecting on exactly what primary care networks are supposed to do.

This starts with their place in the wider system.  The new GP contract says, “The Primary Care Network is the natural unit for integrating most NHS care. Collective general practice can become the footprint on which other NHS community-based services can then dock. And by serving a defined place, the Primary Care Network brings a clear geographical locus for improving health and wellbeing.” (p25)

How networks will start to enact this bold claim is also spelled out in the new contract.  There are seven services networks are to provide against national specifications.  After the set-up year of 2019/20, there are two initial services to be delivered in full in 2020/21.  Networks are to provide structured medication reviews to patients, focusing on particular priority groups.  The pharmacists employed during 2019/20 will be key to the delivery of this service.

They are also to provide a new enhanced service for care homes.  This might be the first new service requiring networks to agree differential delivery across practices, e.g. a lead practice for one or even all of the care homes.  A condition of signing up the network agreement is that services will be provided equally across the network population, and it is becoming immediately apparent networks won’t work via a simple equal division of labour across member practices.

Worth a further pause at this point.  Many CCGs up and down the country have commissioned these types of schemes locally.  It would seem the use of the national GP contract, and its new network function, will lead to the replacement of many locally commissioned schemes with nationally commissioned ones.  We should watch out for how much opportunity the imminent Network Contract DES indicates there will be for local flexibility.

There are three further services that are to “commence in 2020/21 and develop over the subsequent years”.  This is where general practice is taken into slightly less well chartered territory.  While the first service, anticipatory care, is fairly common across the country (although under different names such as “proactive care”) and the idea of identifying and proactively managing the needs of high risk patients is nothing new, what is new is that this service will require a “fully integrated primary and community health team”.   Community providers will even be asked from July to configure their community teams on primary care network footprints.  The relationship (and power dynamic) between the primary care network and the newly configured community team will be critical to future success.

Which takes us back to the wider purpose.  The network is very much about enabling the integration of primary care with other parts of the NHS system.  “A Primary Care Network cannot exist without its constituent practices, but its membership and purpose goes much wider. The NHS Long Term Plan sets out a clear ambition to deliver the ‘triple integration’ of primary and specialist care, physical and mental health services, and health with social care. The Primary Care Network is a foundation of all Integrated Care Systems; and every Integrated Care System will have a critical role in ensuring that PCNs work in an integrated way with other community staff such as community nurses, community geriatricians, dementia workers, and podiatrists/chiropodists.” (New GP contract, p30-31).

The next service is “personalised care”.  Easy to say, hard to understand exactly what it is.  I have read the relevant parts of the new contract a number of times and I still find it hard to pin down.  It seems this is essentially about widening the support provided to individuals beyond purely medical interventions.  Social prescribing and the newly funded link workers will play a prominent role in the delivery of this service.  However it plays out, it is another step in widening the scope and role of general practice through networks in influencing the overall health of local populations.

The last service to be introduced in 2020/21 is supporting early cancer diagnosis.  What is most interesting about this service will be the role of networks in raising awareness of symptoms and uptake of screening in their local neighbourhoods.  Networks may provide a way of practices operating more freely outside of their practices with local community partners.

Finally, in 2021/22 two more services will be introduced.  Cardiovascular disease prevention and diagnosis and, more nebulously, tackling inequalities.  Whilst the former is relatively clear, the latter much less so.  The text in the contract is along the lines of “we will test some ideas and then roll out the approaches that have the greatest impact at the network level”.

Alongside these seven new services from 2020 there will be a new national “Impact and Investment fund”.  Based on a principle of “shared savings” it means networks can gain a financial return from reductions in A&E attendances, emergency admissions, outpatient costs, prescribing savings, and hospital discharge (I assume via reduced length of stay), to then invest in new staff for the network.

It seems, then, the real work begins for networks in 2020 with the introduction of these specifications.  The immediate challenge then should not be simply to tick the relevant boxes that will be sent out by the centre, but rather to use 2019/20 to develop a platform that will be able to deliver against these future requirements, or even better one that can make a real difference to the health and wellbeing of the population it will be serving.

Who Should Host Your Primary Care Network?

I have talked a lot about needing to start with why and build relationships before you get into the discussion about what form your primary care network should take.  But time is short, and form is also a decision that will need to be made.

First things first.  £1.8bn of the promised £2.8bn coming in to general practice in the next five years is coming through networks.  It is worth spending some time making sure these are set up correctly!

Technically practices sign up to networks by signing up to the Network Contract DES (guidance due out in March).  Networks are not to be legal entities of themselves; the aim is explicitly not to create another layer of governance/bureaucracy.  In signing up to the Network Contract DES practices have to identify, by 15th May, “the single practice or provider that will receive funding on behalf of the PCN” (p27).

The contract goes on to say, in paragraph 4.32, that “It is for each PCN to decide its delivery model for the Network Contract DES.  It could be through a lead practice, GP federation, NHS provider or social enterprise partner”.

But which option to choose? How would a new network decide?  It is worth spending some time examining the pros and cons of each of the options.

  1. Lead Practice

Summary: This model feels primarily designed for those practices already at the magic 30-50,000 population, who wish to become a network in their own right.  The money stays close to general practice, but could be a fast-track to inter-practice disputes where more than one practice is part of the network.

Pros Cons
Allows a single practice to receive/manage all the network funding Funding routed through one practice can lead to tensions between practices
Keeps the funding as close as possible to core general practice Liability for expenditure (e.g. employment of new staff) sits with the host practice
Enables rapid decision making and minimal bureaucracy Limited ability to influence as wider general practice within local integrated care arrangements, or to develop services beyond network boundaries

Key questions to consider:

If the network has more than one practice: How will you ensure all practices have an equal say?  How will you ensure transparency between practices? How will you prevent it feeling like a pre-cursor to a future merger with so much of the funding flowing through one practice?

How will you establish joint working arrangements with other networks? How will you create a strong local voice for general practice with other networks?

  1. GP Federation

Summary: This model feels primarily designed for those practices who already have a successful GP federation in place, who want to use the federation infrastructure to strengthen the ability to deliver against, and maximise the opportunities of, the Network Contract.  It will require a clear accountability of the federation to the networks.

Pros Cons
Creates a GP owned host that will allow equity between practices in a network Given the timescales, is likely only to work where GP federations already exist
Creates opportunities for at scale working beyond network boundaries, e.g. extended access funding is often already routed through federations, development of services to impact the Investment and Impact Fund Federation may have priorities different to those of networks, e.g. delivery of existing contracts
Limited liability for the member practices of employing new staff if employed directly through the federation May feel like the networks work for the federation rather than vice versa if not structured correctly
Potential enabler of strong collective voice for general practice in local integrated care working Potential VAT issues if practices want to second existing practice staff into the federation

Key questions to consider:

How will you make sure the federation is working for the networks, and not vice versa?  Who controls the decision making in the federation?  Do/will the networks have enough of a say?  Is there a willingness among federation leaders to adapt the existing governance to meet the needs of networks?

  1. NHS Provider or Social Enterprise Partner

Summary: This model feels primarily designed for those practices already in some form of partnership arrangement with either the local hospital, the local community or mental health trust, or some other organisation.  Without an existing relationship in place it is hard to see how the level of trust could be high enough for practices to be willing to entrust their funding to them.

Pros Cons
May be able to provide additional services for networks such as estates or HR support Is only likely to work where a reasonably advanced existing agreement is in place between local practices and the host organisation
Large turnover organisations will be able to carry liability and any financial risk the networks want to undertake The size and core business of the organisations may mean the networks and their activities are low priority for them
May enhance ability to recruit and support new staff groups e.g. physiotherapists, pharmacists, where host organisation already employs these staff groups Voice of the networks may get confused with that of host organisation in system/integrated care discussions
May be able to offer synergies with own service offerings, e.g. integrating community and primary care teams Distance of the funding from practices

Key questions to consider:

What influence will the network have on the host organisation?  How will it be able to control how network funding is used?  Does the relationship rely on certain individuals, who may only be around for a few more years?  How can networks ensure they can retain a distinct identity from the host organisation?

Conclusion

It very much looks like different solutions will be appropriate for different areas, and that there is no obvious “best” solution that applies to all.  For single practice networks, or those already in a federation or who have a pre-existing relationship with another organisation, the challenge is probably mainly about adapting their existing arrangements to meet the network requirements.  But the greatest challenge may lie with those nascent networks who are formed of a group of practices, with no federation or obvious organisational link.  For them, the best way forward appears far less clear.

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