9
dec
0

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

Posted by Blogs, The General Practice BlogNo Comments

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.

2
dec
1

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

Posted by Blogs, The General Practice Blog1 Comment

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.

25
nov
1

Working Together: Covid-19 Vaccinations

Posted by Blogs, The General Practice Blog1 Comment

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.

18
nov
0

Making a Difference

Posted by Blogs, The General Practice BlogNo Comments

It has been a difficult year.  Coping with Covid-19, and all the challenges that it has brought both personally and professionally has been difficult for everyone.  The first lockdown was hard, but the second lockdown in many ways feels harder, because we understand the scale of the challenge and what will be required to get through it.

This time round some of the fear from the first lockdown has gone, because we know what to expect.  But instead it has been replaced with a tiredness.  Without really having the time or opportunity to recover from the first time round we are having to do it all over again.

For general practice lockdown 1 and lockdown 2 feel significantly different.  When lockdown 1 happened the message was to stop everything to make sure that patients with coronavirus were looked after.  In lockdown 2 the message seems to be that general practice should be open for business as usual, and be absorbing the covid challenges on top of everything else.

Now the ask is for general practice to also take on the covid vaccination programme.

It easy to react from a position of tiredness.  How can we find the energy to take on all the logistical and operational challenges this brings, on top of everything else?  Especially when it feels like we are already running on empty?  I know I personally am guilty of reacting like this.

But the reason I (like many of you) chose healthcare as the industry that I wanted to work in, as opposed to investment banking or commercial law or anything else, was because I wanted to make a difference.  I wanted to not just earn a living, but to do so in way that a made a positive difference to others.

Playing a part in the covid vaccination programme is likely to be my opportunity to make the biggest difference maybe I will ever be able to make.  A vaccine is the only route by which we can re-gain our lives, our economy, our normality.  Without it, as we have seen, the pandemic takes over everything.

So yes it is hard, and it is difficult to summon up the energy and personal resources, but really it is a huge opportunity.  Undoubtedly general practice will rise to the challenge, and play a leading role in taking the country out of the crisis it finds itself in.  I want to be part of it.  I want to know that when it mattered most, I made a difference.

11
nov
0

Time for a PCN Stocktake: 10 points to review

Posted by Blogs, The General Practice BlogNo Comments

A number of PCN Clinical Directors have asked me recently, “What should I be doing now?”.  With so much going on at present, it is no surprise that it is difficult for the leaders of PCNs to remain clear as to exactly where their focus should be.  Just because of the volume of things that are happening, now is a good time for a PCN stocktake.

Investing some time now in a stocktake will help provide a clear sense of direction for the PCN, and help create a renewed sense of focus for the months ahead.

But what should the stocktake cover?  Here are my suggested 10 areas for review:

  1. Member practice engagement. The number one priority for any PCN is its members, because without unity and a sense of collectivism it is very difficult for anything else to be achieved.  It is easy when the agenda gets busy for this to fall to the bottom of the list, but engagement is an ongoing process and it is important PCN leaders do not let it slip.  Within this (of course) is how the PCN has (and plans to) support member practices with covid, flu vaccinations, and (potentially) covid vaccinations.

 

  1. PCN vision/purpose. It is never too late for a PCN to work on what it is trying to achieve and what it wants to deliver for its members and the population it serves.  Member practice engagement is much easier to maintain when everyone is agreed on the overall direction of travel.  Even if you did this a year or more ago, it is important to keep it under review to maintain alignment across the PCN.

 

  1. New Roles. PCNs submitted their recruitment plans for this year back in August, so now is a good time to review progress made against that plan.  It is also important to review how well the new roles that have started are working, and what can be done to both help them become more effective and maintain a focus on retention.

 

  1. PCN DES specification delivery. We are now over a month into the delivery of three new specifications (enhanced health in care homes, early cancer diagnosis, and structured medication reviews).  CCGs seem to vary in the closeness with which they are monitoring PCN performance against these specifications, but better for PCNs to be on the front foot, understand how they are doing, and make any change that are needed themselves.

 

  1. Social Prescribing Service. It is also a requirement of the PCN DES that each PCN provides a social prescribing service to their patients.  According to the Investment and Impact fund (see below) a PCN needs to offer appointments for up to 0.8% of its PCN population between October and March, so for a 50,000 population PCN that is 400 appointments (15-20 appointments per week, depending on whether or not you have started yet).  Is your PCN’s social prescribing service up and running and how many appointments per week is it offering?

 

  1. Investment and Impact Fund (IIF). An ‘average’ PCN can earn up to £21,534 in this year’s IIF (for my blog explaining how it works click here).  In the current absence of any national reporting on PCN performance against the IIF, it is worth at least keeping back of the envelope workings out on where you think you are, so that it doesn’t come as any huge surprise when the dashboard finally appears.

 

  1. Local projects. It is all very well making sure the PCN has done everything that is asked of it in the PCN DES, but to thrive and make a difference locally a PCN needs to undertake at least one project of its own.  Tracking the performance of your own projects is probably more important for the PCN than performance against national directed initiatives.

 

  1. Local relationships. We are still in the start up period for PCNs, and crucial for future and ongoing success are the relationships a PCN has in place with its local health and social care partners.  Are there individuals in the community trust, acute trust and mental health trust the PCN can contact to sort out issues or take new initiatives forward?  Are relationships in place with the local voluntary sector to enable the nascent PCN social prescribing service to thrive?  Is the PCN working well with the other PCNs in the area?

 

  1. Preparation for extended access. Looming large on the horizon is the transfer of responsibility from CCGs to PCNs for extended access form April next year.  We are still awaiting guidance on the details of this and what this is going to look like in practice, but a PCN would be wise to at least have started working through what it wants the service to look like, and any major changes (e.g. locations etc) it wants, so that when the guidance does finally land the PCN is in position to move quickly and not lose out on the opportunity simply because the timescales are (inevitably) tight.

 

  1. Preparation for next year’s PCN DES specifications. We have also had a pretty good preview of at least some of the outstanding specifications that are on the way, in particular anticipatory care and personalised care which were published in draft last year before they were dropped from this year’s requirements.  A PCN would do well to plan how it intends to meet the requirements of the new service specifications, so that it can make sure it has the staff and resources in place to deliver it when the time comes.
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