Access remains a highly contentious issue and the latest publication from NHS England regarding the 2022/23 contract updates has resulted in a wave of concern from some GPs and unhelpful headlines in the usual suspects of newspapers.

Negativity permeates a lot of what we are doing as a professional sector and in many parts of society. It is easy to look at perceived problems and often hard to focus on the positives.

Of the Clinical Directors, PCN Managers and GP partners I have discussed this with, once we spent some time assessing the impact on them and their practices, it has been evident that this change is likely to bring about a number of positive outcomes. I wanted to share this with a wider audience to hopefully improve the perception of the changes.

Is there a greater time commitment?

If you are in a practice that has never delivered the Extended Access requirement and you have limited engagement with Improved Access it may feel like an increased obligation.

In most other cases it will be the same and, in some areas, could be a reduction of time. There are areas who have been working under Improved Access at or close to 45 minutes per 1,000 patients plus the 30 minutes of Extended Access. For these areas the strict obligation will be easier to provide.

Services I am involved with have been operating on a model of 37.5 minutes and in practice we have been delivering closer to 50 minutes under Improved Access at the request of our member practices. Consequently the new combined requirement will be between 7.5 and 20 minutes less than currently provided.

Many other areas are the same, but it is essential to ensure that the time requirement is tracked on a like for like basis.

Is there sufficient funding?

The letter states that NHSE will ‘bring together, under the Network Contract DES, the two funding streams currently supporting extended access to fund a single, combined and nationally consistent access offer…’. This means that for every patient £7.44 will be available.

Currently £6 per head is commissioned by the CCG and is paid to the local provider of Improved Access. Some PCNs took responsibility for this funding and commissioned their own Improved Access in 2020, others received the service indirectly through federations.

By moving this fund into the PCNs it is arguably the first significant funding stream that can significantly improve the performance and structure of the network.

The following table provides a quick reference to the new time obligations and funding to support it:

It is important to recognise that some of this money is already being used by practices and other funding will be with federations or other third parties. The effect of moving these funds into the PCN need to be carefully considered locally so it does not destabilise other services which may be relying on top slicing these revenue streams.

Will the workload increase?

The guidance is vague and in many ways that is far better than the current requirements managed by CCGs. One of the biggest challenges with Improved Access contracts was the focus on appointments of 15 minutes. This resulted in a limiting factor which either excluded or made it very difficult to count many of the more innovative uses of the additional time.

Group consultations, tissue viability clinics and DVT management clinics were some examples that delivered excellent patient outcomes but struggled to demonstrate the appointment counting criteria.

The new requirement simply states that the time is used for ‘any general practice services’. A narrow interpretation for this could be a full suite of services but I would recommend that unless further guidelines are brought out, we use a broad interpretation. Our focus will be on delivering those general practice services which are making the biggest impact on our patient’s needs and preferences.

In some areas this may be a full range of services in others it could be a focus on cohorts of patients. I am aware of a PCN who focuses on weekend clinics for the elderly as they discovered it was the best time for family and carers to help the patient travel to the practice.

This type of patient focused service modelling is at the heart of the original PCN concept and this is an opportunity to start shaping support around them. This is the first requirement in the preparation stages outlined in the guidance.

Sharing the workload between practices by developing shared services across the PCN should improve the levels of demand on practices if managed correctly.

Will much change?

For many practices probably not. Enhanced Access is not significantly different than the current arrangement and as argued above it provides new opportunities to PCNs in terms of service design, improved funding and integrating workloads.

The option remains for PCNs to take responsibility for the funding but to agree with practices and with other providers to continue providing existing levels of cover and services. As long as these meet the minimum requirements and the parties are happy with this approach this allows continuity whilst giving more financial control to the PCNs.

This may well be the stop-gap position whilst a longer term review and service redesign process is instigated by the practices to shape services in the future.

If you are in an area with poor service availability with current Improved Access providers, this situation should improve as you take greater control. There are also areas where the CCG top-sliced the £6 figure, so in these areas the full amount will be made available to practices for the first time.

There will be exceptions to this principle but in general this is a change which should be seen from a positive, pro-GP perspective.

Next Steps

We have until October before the new requirements go-live and first drafts of the Enhanced Access Plans need to be submitted by 31 July 2022. This time will fly by quickly so it is better to get started at the earliest opportunity.

It is likely that these plans will be subject to a form of localised template but in the meantime PCN teams can look at current arrangements, discuss with the practices how they want to manage the transition from the current service and speak with your current Extended Access providers.

You can also engage with your patients at the earliest opportunity. Use different data sources to build a picture of the changes that are most likely to improve services as a whole.

This information will be a great starting point to manage the transition to the new specification and you may be surprised about how little change is needed. For others this is a chance to start implementing some of those longer-term aspirations you have had and to start those service improvements which have been delayed in recent years due to the pandemic or a lack of funding.

It can be hard at times to be optimistic, but I am convinced from the discussions I have had over the past few days that this is a change that should be embraced rather than feared.

The government published its White Paper “Joining up Care for People, Places and Populations” on the 9^th February, describing itself as “the government’s proposals for health and care integration”.  This is apparently one of a set of reforms, as it sits alongside the Health and Social Care Bill and the Adult Social Care Reform white paper.

There is no getting away from the meaningless fluff that surrounds descriptions of integration in the paper (e.g. “Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole” p17).  The terminology within the paper is both over the top and (at best) confusing.

The paper clarifies (p18) that a “neighbourhood” is “an area covered by, for example, primary care and their community partners”.  You would think this would be called a PCN, but the PCN nomenclature appears to be have been dropped within this paper and replaced by neighbourhood.  A “place” is a locally defined geographic area typically 250-500k population, and a “system” is a larger area with a population of about 1 million.

In fact PCNs only get one significant mention in the paper, and that is primarily to signpost the fact that they are being reviewed, “GP practices are already working together with community health services, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as Primary Care Networks (PCNs). Building on existing primary care services, they are enabling greater provision of proactive, personalised, coordinated and more integrated health and social care for people closer to home. NHS Chief Executive, Amanda Pritchard, has asked Dr Claire Fuller (CEO Surrey Heartlands ICS) to lead a stocktake of how systems can enable more integrated primary care at neighbourhood and place, making an even more significant impact on improving the health of their local communities. This will report later in the spring.”

For a reason that I am not clear on, PCNs have shifted from being the central plank and foundation of integrated care systems, to something that contribute towards the overall ambition for integration – make of that that what you will.

The paper tries to distinguish between what will happen at the system level and at a place level.  There is the sticky issue of whether the NHS or Local Authority is “in charge” at a place level, and the solution the paper comes up with is that, “There should be a single person, accountable for shared outcomes in each place or local area, working with local partners (e.g. an individual with a dual role across health and care or an individual who leads a place-based governance arrangement).” p11.

However, “These proposals will not change the current local democratic accountability or formal Accountable Officer duties within local authorities or those of the ICB and its Chief Executive”, which does rather beg the question of what power or authority these newly accountable individuals will have.

The suggested governance model for place is via a ‘place board’, “a ‘place board’ brings together partner organisations to pool resources, make decisions and plan jointly… In this system the council and ICB would delegate their functions and budgets to the board” p34.

General practice therefore needs to work out how it is able to be an effective member of, and be able to influence, this place board.  This will inevitably require the PCNs within a place area to find ways of working together and to be able to create a unified voice.

The autonomy of these place boards is still open to question.  Despite a lot of rhetoric about the need for local areas to determine local priorities, the pull of the top down approach has once again proved too difficult to resist, “We will set out a framework with a focused set of national priorities and an approach from which places can develop additional local priorities” (p23).   A new set of national priorities is on its way for implementation from April 2023.  This means places will receive their must-do list which they will undoubtedly be heavily performance managed on, but of course can also set some additional priorities for themselves if they would like.

That said, the ambition remains for services and spend to be put under the control of place based arrangements, so I still think it would be wise for general practice to ensure it plays a central role within them.  One thing the paper is clear on is that general practice funding is not to be ringfenced from other spending, but rather included within a single system funding envelope (p36).

There are promises to have fully integrated shared care records across organisations and seamless data flows across all care settings in place by 2024, but if the last 20 years has taught us anything it is don’t hold your breath.

There is a whole chapter on workforce integration.  What is notable about this is more what it doesn’t say than what it does.  It talks about the pivotal role of link workers and care navigators in joining up care, about pharmacist integration, and about making better use of occupational therapists, but it never once references the additional roles coming into PCNs through the ARRS.

Overall the paper continues the national drive towards integration, and reinforces the need for general practice to make sure it is playing a central role in the developing place based arrangements for their area.  What is potentially of most concern is the shift away from the importance of PCNs and whatever lies underneath that.