16
feb
0

The Challenge of Being a PCN Clinical Director

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The role of a PCN Clinical Director is more challenging than it has ever been before, and yet we are about to see a huge turnover in those undertaking these roles.  Why is the role so different now, and how can those taking it on for the first time now even hope to be successful?

It may not feel like it, but it is now three years since we were first introduced to Primary Care Networks (PCNs).  They first appeared in the NHS Long Term Plan which was published in January 2019, which was then quickly followed up with the new five year GP contract the following month with the PCN DES for general practice.

After three months of set up, PCNs were formally established on 1 July 2019.  One of the requirements was that each PCN had a Clinical Director in place.  Many of these Clinical Directors agreed to take on the role for an initial term of 3 years.

Unfortunately the initial funding of 0.25wte per 50,000 population was wholly inadequate for the workload and expectation placed upon these new leaders.  This situation was not helped by the ongoing national refusal to make any funding available for PCN managers to lighten the burden on PCN CDs.  Whilst the funding has (belatedly) been temporarily increased to 1 wte and some (non-recurrent) funding has been made available for management support this year, it has never been done in a way that allows PCNs to invest more into PCN leadership on a permanent basis, or that enables those leaders to give up their other work and create more time for the role.

The PCN CD role has changed immeasurably in the last three years.  In their first year the (not insignificant) challenge was persuading practices to work together.  But since then PCN CDs have had to deal with Covid, the vaccination programme, a huge increase in staffing via the ARRS scheme, and an ever increasing set of delivery requirements, all during a period of transition into integrated care systems.

Let’s not forget, all of this has been set within a context of general unease across the service with PCNs.  At a number of points across the last three years there have been threats of widespread resignations from the PCN DES, and that threat is still hanging following the ballot from November last year.

It is no surprise, then, that many of those who put themselves forward to be a PCN Clinical Director back in 2019 are saying that enough is enough, and that it is someone else’s turn to carry the baton now that the initial three year term is up.

The problem is that most of these individuals have grown and developed with the role over the last three years.  They possess leadership skills and experience that they did not have when they started.  Their PCNs need them in the CD role now more than they ever did.  But the system has treated them in a way that means it is unsurprising that many do not want to continue.

And so we are in a position where in many PCNs, someone new, or maybe even two new people, are taking on the role.  The challenge for these new incumbents is even greater than it was for their predecessors because the roles are so much bigger now, and the expectations on PCNs are so much higher.

It will not be easy, and it will be down to both the local practices within a PCN and the local system to support this new wave of leaders so that they may also have a chance of success within the role.

It is with all of this in mind that myself, along with PCN CD Dr Hussain Gandhi and PCN expert Tara Humphrey, have set up PCN Plus.  PCN Plus is a development programme for those taking on the PCN Clinical Director role, and provides training for new PCN leaders in how to be successful in the role.  You can find more information about PCN Plus here.

9
feb
0

The Influence of General Practice on Integrated Care Systems

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The shift to Integrated Care Systems is going to be a difficult one for general practice.  The luxury of Clinical Commissioning Groups (whatever you might think of them) was that they put general practice at the forefront of decision-making.  Of course that is not really how they worked out in practice, but at least their existence ensured a strong presence for general practice in any system-wide decision making.

That, however, is all about to change.  It may well be that the statutory change to Integrated Care Systems and the formal abolition of CCGs is not due to take place until July, but these changes  are already being made and the new system will be up and running sooner rather than later.  The statutory representation of general practice falls to a solitary GP on the ICS Board, and they will have no requirement to be there in a representative capacity for the profession.

In a recent podcast with Dr Jaweeda Idoo from Greater Manchester, where devolution has accelerated the ICS agenda, it became clear that there are numerous levels between any individual practice and the ICS Board.  Each practice is in a PCN.  Each PCN works together with other PCNs in a “place” area.  The 10 place areas from across general practice work together in a general practice board for Greater Manchester.  Representatives from the general practice board are on the primary care board (incorporating wider primary care partners such as pharmacists, opticians and dentists).  Representatives from the primary care board sit on the Provider Board.   The full ICS Board then also includes CCG and Local Authority representatives.

There are a lot of layers.  The distance between a practice and the ICS seems vast.

In Greater Manchester general practice has retained a voice, but this seems to be due to the influence of certain individuals, such as Manchester LMC CEO Dr Tracey Vell, and a seemingly shared belief in the pivotal role general practice plays within the system.

But Integrated Care Systems are not being designed to maximise the voice of general practice.  Instead we have this sense of predatory hospital trusts, encouraged by the Secretary of State, considering how they can bring general practice under their wing and keep their needs central within ICS discussions.  Practices in areas more dismissive of the role of general practice than Greater Manchester may find themselves even further down the pecking order.

What, then, is general practice to do?  There is a school of thought that the only way to increase the influence of general practice is to make the service more relevant to the system discussions.  By doing more to impact the system, such as taking on outpatient and more minor procedures from the acute environment, or managing cohorts of the unwell at home, then it forces the system to listen.

There is another school of thought that general practice has not only react to proposals put forward by others (which appears to be the default system position), but must proactively generate ideas and strategies of its own in order to increase its sway in the discussions.  By bringing new things to the table general practice can create its own relevance.

While either of these things may or may not turn out to be true, my sense remains that the starting point has to be the development of a sense of unity and collective identity across general practice in any area.  At present general practice often feels divided between practice GPs, PCN CDs, Federation Directors, CCG GPs, LMC GPs, and even CCG primary care teams.  In the new system, however general practice chooses to work to generate influence, it has to do it together.  There can only be one general practice “team”, and everyone has to be on it.

For leaders in general practice preparing for the shift to Integrated Care Systems the most pressing priority right now has to be working to create this unity.  Divisions in the service sometimes run deep, but it is in everyone’s interests to put these to one side, to bring together all the skills and expertise that exist across the service, and work to unite these to give general practice the best possible chance of meaningful influence in the new system.

2
feb
0

Why Would Sajid Javid Claim to Want to Nationalise General Practice?

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On Saturday the Times reported a plan by Sajid Javid to ‘nationalise’ general practice.  It seems (once again) general practice has become something of a political football.  What are we to make of this latest report?

We need to put this latest development within the context of everything that has happened in recent months.  In October last year the government, clearly frustrated by complaints in the Mail and other elements of the press about challenges with access to a face to face appointment for a GP, pushed NHS England into the production of their document “Our plan for improving access for patients and supporting general practice”.

As a result the profession, already incensed by the lack of support from NHS England earlier in the year over the same issue, voted in support of a mandate for strike action.  Not, one would think, the response the government was looking for.

At this point (in November last year) the Health and Social Care Committee, now led by a transformed Jeremy Hunt seeking to use his position chairing this committee to undermine the government at any point, launched an Inquiry into the Future of General Practice.  Evidence for this inquiry can be submitted until this Friday, 4th February.

The Times article indicated that a review of General Practice is “planned” by Javid, so we can assume this is not the same as the Health and Social Care Committee Inquiry.  There are undoubtedly politics that we are not aware of between Hunt and Javid also at play, but what the Secretary of State certainly won’t want is Hunt’s Committee telling him what he should be doing with general practice.

The other important piece of context for this article is the wider shift to integrated care, and what this means for general practice.  As I discussed a couple of weeks’ ago, the Planning Guidance for the NHS seems very geared towards the role general practice can play in support of acute trusts, in particular in relation to the rollout of thousands of virtual wards.

A review of PCNs was also announced in November last year, and interestingly this review is now framing itself in terms of what “integrated primary care” looks like.  In this video the leader of the review Clare Fuller does not reference PCNs once.  This review is due to report next month, so it is not beyond the realms of imagination to think that this is the review that Javid is referencing in the Times article.

This would also explain the timing of the article, although of course all this is being carried out at exactly the time that the newly elected GPC committee, armed with their strike mandate, are negotiating the first contract.  This government, for longer than most of us can remember, wants better access to a GP above all and everything else, and if negotiations are not going well this might be the perfect time to threaten nationalisation to move things along.

The argument for organising health services around the needs of hospitals (as opposed to the health needs of the population) is so antiquated that it is hard to believe that it is being taken seriously.  That said, with this government anything is possible, and there are disturbing trends within Integrated Care Systems and the guidance around them towards creating primacy for the needs of hospitals.

But overall my sense is that general practice has very much become a political football, and that most of this is political game playing.  I don’t really think Sajid Javid wants to nationalise general practice, and to end up in a full on dispute with the profession, but I think there are things that he does want and reports like this are simply a means to help him get them.

26
jan
0

5 Things to Watch Out For in 2022

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What is on the horizon for general practice in 2022?  Here are 5 things to watch out for in the year ahead.

February: Contract Negotiations.  We are three years in to the 5 year deal agreed in 2019, so you would think that contract negotiations this year would be relatively straightforward.  However, once you throw in Covid, the government’s concern with GP access, a new GPC leadership team, and the vote in support of industrial action made by the profession at the end of last year, the negotiations this year could well be a spikier than normal affair.  Despite the profession’s reaction there has been no softening of the national stance on GP access, and so it will be very interesting indeed to see what comes out of this particular set of negotiations.

March: PCN Review Report.  In November last year a review of PCNs was announced, and how “they will be working with partners across newly formed integrated care systems”.  Potential concerns were highlighted at the time, namely that it implied a need for more national control over PCNs, that it could signal a shift of ownership of PCNs away from practices, and that it may very well further distance PCNs from the pressing issue of general practice sustainability.  This report is due in March, most likely coinciding with whatever comes out of the contract negotiations, and there is a good chance it will have big implications for general practice.

June: 3 years of PCNs.  It may only feel like yesterday but in June it will be three years since PCNs were first established.  PCNs now, with their large team of additional role staff and increasing set of delivery responsibilities, are significantly different from what they were back in 2019.  However, three years may also mark the end of the tenure of many of the initial PCN clinical directors.  While we have experienced some turnover of CDs already, this year could well see a much a greater turnover with many coming to the end of the term they initially agreed, and taking on the role may prove a tough challenge for those coming new into the role this year.  How this affects PCNs as a whole is something only time will tell, but unless more support is put in place it is unlikely to be positive.

July: Integrated Care Systems go live.  It feels like we have been living in the shadow of integrated care systems for some time now, but (according to the new planning guidance) they will finally go live in July this year.  This means CCGs will formally be abolished, and general practice will be left to fend for itself amongst the other providers as we all ‘work together’ to agree how care is organised and how resources are divided.  The extent to which general practice can influence and impact these new systems may well be very important in determining the level of local investment and support in the service going forward.

October: Shift of Extended Access to PCNs. Well, maybe.  This shift was supposed to happen in April last year, and then in April this year, and now in October this year, and the continual delays do raise the question as to whether this shift will ever really happen.  But if it does it may well spell the end of financial sustainability for the significant number of GP federations that rely on this funding, and this in turn could well create difficulties for both local practices and PCNs.  It is an issue that when the guidance (finally) comes out will need some working through to ensure we don’t end up with more problems than we have now.

19
jan
0

What this Year’s Planning Guidance Means for General Practice

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Each year the NHS publishes planning guidance.  This year is no different, and on Christmas Eve (happy Christmas everybody…) true to form the NHS published “2022/23 Priorities and Operational Planning Guidance”.   It outlines for the NHS what needs to be achieved in the year ahead.

While it is not a document specifically aimed at general practice (rather it is aimed at the NHS as a whole), it provides an interesting perspective on how general practice is viewed within the system, what the priorities for general practice are likely to be, and gives some indication as to what will feature in next year’s GP contract.

The document sets 10 priorities for the NHS.  General Practice explicitly features in one of them, namely to, “Improve timely access to primary care – maximising the impact of the investment and Primary Care Networks (PCNs) to expand capacity, increase the number of appointments available and drive integrated working at neighbourhood and place level” (p6).

So first off, in case anyone thought there might be some national backing off from the October guidance that generated such a backlash (including a mandate for national strike action for the GPC), there is a clear reinforcement of the need for the paper to be implemented (“In line with the principles outlined in the October 2021 plan, systems are asked to support the continued delivery of good quality access to general practice through increasing and optimising capacity, addressing variation and spreading good practice” p25).

More interesting is the newer theme that pervades the text around integration.  Integrated Care Systems go live next year, although this document confirms that this will now happen on July 1st not April 1st to allow time for the bill to pass through parliament.  Systems are exhorted to, “maximise the impact of their investment in primary medical care and PCNs with the aim of driving and supporting integrated working at neighbourhood and place level.  Systems are asked to look for opportunities to support integration between community services and PCNs” p24.  The review of PCNs will be reporting in March, and I wouldn’t be surprised if it marks a shift of PCNs away from ownership solely by practices.

Systems will also be judged by the extent to which their PCNs have made use of their ARRS allocation, and are also asked to support employment models across organisations, “Systems are expected to support their PCNs to have in place their share of the 20,500 FTE PCN roles by the end of 22/23 and to work to implement shared employment models” (p24).  It is interesting that underneath the opportunity for PCNs to use the ARRS funds there is a top down pressure on local systems for all the money to be spent.  Indeed, the rationale used is not to support general practice, but “to support the creation of multidisciplinary teams” (p9).

There is a further notable nuance that PCNs (not practices) are treated as the unit of general practice in the guidance.  It claims that there will be, “ a suite of national GP recruitment and retention initiatives to enable systems to support their PCNs (not practices) to expand their GP workforce and make full use of the digital locum pool” (p9).  We also won’t hold our breath in anticipation of all the same additional GPs we have been promised for the last 5 years…

There are two other major items of note for general practice in the guidance.  The first is the big push in the guidance on the roll out of virtual wards.  The ambition set is that by the end of 2023 there will be 40-50 virtual wards per 100,000 population.  These are to be based on a partnership between secondary, community, primary and mental health services, and they “should only be used for patients who would otherwise be admitted to an NHS acute hospital bed or facilitate early discharge” p21.  £200M in 22/23 and £250M in 23/24 is being made available to develop these wards, although given the numbers of wards expected how they will work is a mystery, as my back of the envelope calculation gives each ward less than £10,000 to operate.

The other item of note is a promised new IIF indicator for PCNs to incentivise contributions to a minimum of 2 million additional pharmacy consultation appointments in 2022/23.  According to the guidance (p25) this will move “more than 15 million appointments out of general practice”!

Overall, the main takeaway is the pressure that will come around ‘integration’ – PCNs and PCN staff to work across organisations, multidisciplinary teams, multi-organisational virtual wards, joint working with pharmacies, and (of course) new integrated care systems in charge of everything.  What could possibly go wrong?

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