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Three Things Practices Can Do to Make the Most of the Additional Roles Reimbursement Scheme (ARRS)

Posted by Blogs, The General Practice Blog2 Comments

The most significant additional investment into general practice at present comes via the PCN DES, and the much of that arrives in the form of the ARRS.  We are three years into the five year deal, which means there are only two years left of significant growth of this funding.  Further similar increases in future seem unlikely.  How can practices make the most of this additional resource?

The scale of the opportunity remains relatively high.  Most PCNs have not yet spent their full allowance to date, and some of last year’s expenditure was often used for the vaccination programme rather than being deployed recurrently.  This means that many PCNs have getting on for £1M available to invest in new roles over the next two years.

There are three things that practices can do to make more of the opportunity of the ARRS.  The first is to think differently about the roles that are needed.  To date the process of identifying which roles to employ has often consisted of looking at the list of available roles and choosing the ones that the practices most liked the sound of.  But continuing to do this is likely to mean practices will fail to make the most of the opportunity this funding presents.

We know that general practice workload will continue to increase. Demand from the local population will continue to go up, and the advent of ICSs is likely to accelerate the shift of activity from secondary to primary care.  At the same time, the number of GPs continues to fall, as despite the push for extra GPs the number leaving continues to exceed those entering the profession.

This means that for general practice to be resilient into the future the model has to change from one where all the activity coming into practices defaults to a GP, to one where the service is led by GPs but delivered by a much wider range of professionals.  This is the only way it will be sustainable.

What the ARRS provides is an opportunity to bring in the new roles that are needed and change the way general practice operates.  If practices spend some time working out what workforce they want in two years’ time, they can then use the opportunity of the ARRS to create a more fit for purpose workforce and employ the roles that will enable this vision to be realised.

The second is changing the approach to the PCN DES work.  At present the approach is generally that practice staff focus on practice work and PCN staff focus on PCN work, and only support practice work if they have any capacity left over.  As a result the additional roles feel like an additional burden on practices because of all the training and supervision that is required, and their time is sucked up meeting the increasingly onerous requirements of the PCN DES.

A better way to think about this is in terms of the totality of the workload (across practices and the PCN) and the totality of the workforce, i.e. how do we incorporate the ARRS staff to create a total workforce able to best support both the practice and PCN requirements.  By keeping such a strong division between practice and PCN work we are preventing ourselves from making the most of the workforce we do have.

The third is not to underestimate the need to invest in a change or redesign process to go alongside the introduction of the new roles.  Incorporating the new roles effectively means changing the way we operate.  If we don’t we are simply trying to plug holes in a sinking ship, rather than building ourselves a new boat.  But this of course requires additional investment and time, both of which are in short supply.

One way round this however is a creative use of the care coordinator role.  So if, for example, we are changing the way practices in a PCN manage prescriptions using pharmacists and pharmacy technicians, then we can use a care coordinator as a change resource to support the change of the prescription process.   Once they have done this they can then be a resource to support the change to the way MSK presentations are managed across practices using an ESP (etc etc).

The ARRS is an opportunity for practices to start to build a model that will be resilient into the future.  But it won’t happen automatically, and practices need to act now to make the most of it because in two years’ time it may well be too late.

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Are PCNs the Battleground for General Practice?

Posted by Blogs, The General Practice BlogNo Comments

The NHS is undergoing some significant changes right now, and the implications for general practice are potentially hugely significant.  Could it be that whoever ends up providing the support that PCNs need in fact ends up being the organisation that controls general practice?

PCNs are the place to where all the additional resource into general practice is being channelled.  This is the crux of five year deal agreed in 2019, and when the GPC tried to renegotiate this this year, and put more into the core contract, they were met with short shrift.  Instead the message was very much that PCNs are here to stay.

The priority for the NHS with the shift to Integrated Care Systems (ICSs) is for general practice to be able to act as a “partner” in the system.  What this means is that in any individual “place” area they want one way of contacting and doing business with general practice (instead of c50  if there are for example 40 practices, 7 PCNs, 2 federations and an LMC).

It is not a huge leap to think that not only will any additional resource for general practice continue to be channelled through PCNs, but also that ICSs will shift all additional, non-core GP funding through PCNs.  Indeed it would not be a huge surprise if all the PCN funding shifted at the end of the 5 year contract from national terms to local ICS-based terms, to allow “effective local tailoring of the resource to local needs”.

PCNs, therefore, will continue to grow, and potentially take on a increasing role in relation to access and quality across all of its member practices.  PCNs already need far more of an infrastructure than they have (think training, HR, finance, governance, performance etc), and this need only becomes more pressing with further growth and investment.  There also needs to be a bringing together of the PCNs within any place area, to make it workable for the system as a whole.

Where does this infrastructure come from?  One of the other provider organisations in the ICS is the most obvious solution.  Such an integration sorts out the infrastructure issue, as general practice and PCNs can simply tap into the already existing quality, estates, HR (etc) functions within that organisation.

While this might feel like too big of a leap, our Secretary of State seems to have already nailed his colours firmly to the mast with his support for the recent think tank paper extolling the virtues of the vertical integration of general practice and its assimilation into acute trusts.  ICSs want to be able to do business with general practice, and this will be far easier if it is all sitting within an existing organisation with a Board and Chief Executive and clear lines of accountability.  For the other provider organisations within an ICS, one of them taking this on seems a far more attractive option than anything else, if for no other reason than it limits the number of providers around the ICS table.

The alternative is that general practice takes this on and organises itself.  The GP organisations in an area can choose to come together and create a single leadership team, and bring the LMC, federation and PCN leaders all into one group.  This group can start to operate as the leadership team for local general practice.  They can build on any existing infrastructure they have, such as that within their local federation, and work with the CCG primary care team to take on more of the resources that are currently sitting there.

I am not underestimating how difficult a task this is, but there are places up and down the country who are starting to work this through and put it into place.

Nobody else will want this.  It is easier for them to work with the existing provider organisations.  For them, waiting for the inevitable requirement for someone else to need to take this on is the easiest option.  While it might feel like a big change for general practice to make, it might also be the only opportunity general practice has to secure its independence into the future.

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How is our PCN doing?

Posted by Blogs, The General Practice BlogNo Comments

As we come to the end of the third year of the PCN it is a natural time to review how things have gone so far, and to consider what might need to be different going forward.  But how do we know how our PCN is doing?

I am struck by the number of PCNs that tell me that they are “behind other PCNs”, even when to me they seem to be extremely well.  Sometimes we hear success stories from other PCNs and assume that this is what “everyone” is doing, and that we are somehow falling behind.  But PCNs are not a race or a competition, and it is up to each PCN to determine what success looks like for itself.

I wrote last time about the importance of a PCN vision, and the need for the practices in a PCN to set their own direction to determine what they want from the PCN.  One measure for how well we are doing is the progress we are making against our own priorities for the PCN (which may well be different from those of other PCNs).

But it is not the only measure.  At their core, PCNs are a joint working initiative across the member practices.  Whatever desired outcomes the PCN has set, a key metric for any PCN is the level of trust that exists between the members.  The more we trust each other, the easier working together becomes.  And this is where we get into the importance of the culture of the PCN.

When you ask member practices about the PCN and how well it is doing the response is rarely about whether the PCN is achieving its goals.  Instead the framing of the response is often about how involved they feel in the work of the PCN, its relevance to them, and its impact (positive or negative) upon them.

So while in part the response is about the level of alignment between the PCN’s goals and the practice or individual’s goals (e.g. is it reducing or increasing my workload), it is also about the way the PCN operates.  Do member practices feel involved in decision making?  Do they feel able to shape the activities of the PCN?  Do they know what is going on?

This is essentially what the culture of the PCN is – “the way we do things around here”.  If the culture is strong, is built on a solid and developing foundation of trust, and the member practices are happy with it, then the PCN has a solid foundation to go on and achieve whatever it wants to in the years ahead.  But if there is unhappiness with the culture, complaints about the lack of communication, disengagement from practices, and a general lack of trust, then regardless of what has been achieved so far it is likely to be a difficult road ahead.

Determining how well we are doing in a long term joint working enterprise like a PCN needs to be as much in terms of how we do things as what we have achieved.  If we are taking time out to take stock of where we are as a PCN (and I strongly recommend that you do!), then make sure to spend as much time on how the PCN is working as what you want it to achieve.

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Time to Revisit the PCN Vision?

Posted by Blogs, The General Practice BlogNo Comments

It is always an interesting to hear the response when I ask the leaders of any PCN whether they have a PCN vision.  Most commonly they recall doing some work on this a few years ago when the PCN first set up, but equally could not tell you what it is.  So is it time to revisit the PCN vision?

The problem is most of the work that goes into establishing what the PCN vision should be focusses on the words in the vision itself.  PCNs end up with some form of ‘vision statement’ that acts as the end product to the work, which is often some noble statement about supporting people to have better outcomes and working in partnership (etc).  But what happens to it, other than it ending up on the PCN website or being used as evidence in the latest PCN maturity matrix assessment?

It is not a surprise, then, that members of the PCN cannot remember what the PCN vision is, because its relevance to the members is limited at best.

The point of a vision statement is to establish why you are undertaking the enterprise in the first place.  Why has each practice signed up to the PCN DES?  What do we want out of it?  What problems are we all experiencing that we think the PCN may be able to help with?  If the vision statement can get to the heart of this, it becomes much more powerful.

The simpler the PCN vision is the better.  Compare these two PCN vision statements (these are real, anonymised PCN vision statements):

  • Member practices of XXX PCN will work together to improve access to the local community. Extending the range of services available to them, by helping integrate primary care with wider health and community services. We will work in collaboration with others – health and social care services, the voluntary sector, community groups and local people – to make best use of available resources, creating a seamless approach, whilst making sure that everyone gets the right support, in the right place, at the right time.
  • To create a sustainable future for our practices.

Which is most powerful?  The point of a vision is not that it creates a statement that everyone can sign up to (but ultimately can’t remember), but rather acts as the guiding force behind the decision making within the PCN.  The vision tells us where we are going, and everything else we do should fall in line behind that.

This is why having a clear vision for the PCN is really important.  If we do not have a shared vision across our practices of why we are participating in the PCN in the first place, then we have no clear point of reference for our decision making.  In the absence of our own direction, we let the PCN DES itself dictate our actions.

The PCN DES is produced in a way that enables the general practice leaders that negotiated this additional funding and resources for general practice to justify the investment.  The additional £2bn that it brings has to come with an output, and so those in charge can point to things such as its contribution to the long term plan (the PCN DES specifications) and enabling general practice to work within the integrated care system.

But that does not mean that this has to be how it is used by practices.  While the contractual requirements are there, what practices need to do is work out how they want to make the most of the opportunity that it brings.  Practices can set their own goal or goals, and then the challenge is to work around the contractual requirements to achieve these goals, not simply provide what others want.

If you do not know what your PCN vision is, now is definitely time to take stock and consider what you want it to be.  If you don’t, you are defaulting to a position where others are effectively deciding what you do (because you are simply led by the PCN DES requirements).  Take the time to come up with more than a statement that everyone will agree to. Come up with what you all want to achieve, and that can guide your collective decision making and actions going forward.

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Should Practices Opt-Out of the PCN DES?

Posted by Blogs, The General Practice BlogNo Comments

April will mark one of the few opportunities practices have each year to opt out of the PCN DES. Is this a move GP practices should be considering, or do the benefits of staying outweigh the additional requirements on practices?

The lack of a negotiated contract for this year means the existing 5 year deal for general practice agreed by the GPC in 2019 rolls through into next year.  The response by the GPC has been a thinly veiled encouragement for practices to consider opting out of the PCN DES, “Should practices decide that they cannot accommodate the below changes, that their patients would be better supported outside of the PCN DES, that the practice would operate more effectively and safely outside of the PCN DES or any other reason, they are able to opt-out” (GP Contract Changes, BMA).

This theme is continued in the BMA’s recently published “Safe Working in General Practice”, which states, “There is an increasing view that the requirements of the DES outweighed the benefit brought by the investment into practices and ARRS staff… Practices will need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their wider practice, and their present workforce”.

This all feels somewhat disingenuous, and more of an attempt by the BMA to score political points over NHS England than genuinely putting the interests of practices first.

The reality of the 2019 deal and the introduction of the PCN DES is that it put an additional £3 billion funding into general practice, £2 billion via the PCN DES.  The majority of that funding has not yet come through.  We are only half way through the recruitment of the ARRS roles, the IIF funding has been limited due to covid and grows significantly over the next two years, and enhanced access brings £6 per head under the control of PCNs that previously in most places came nowhere near practices.

From a staffing perspective there are no new GPs, and whatever the promises (5,000 GPs, 6,000 GPs etc) there are unlikely to be any anytime soon.  The only way for practices to manage the ever increasing workload is to use different roles.  Notwithstanding the challenges of training, supporting and integrating these roles, they are the only realistic route for practices to find a way of managing the workload.  100% reimbursement (even if that doesn’t mean free) for these roles is not a bad deal.

PCNs are also the only route by which general practice can influence the newly developing integrated care systems.  The future NHS is not interested in any provider that wants to stand alone and not work in partnership with others.  If general practice wants to continue to be able to have a voice post-CCGs then it needs to work on how its PCNs can influence local arrangements.

The alternative is, as the BMA points out, to opt-put of the PCN DES.  This means practices will lose out on the PCN funding, the ARRS staff and worse, “NHS England is likely to transfer the funding, requirements and staff – likely via TUPE (Transfer of Undertakings) – to Trusts or alternative providers to maintain as much of the PCN DES as possible without general practice.” (GP Contract Changes, BMA).  Given the current Secretary of State’s penchant for nationalising general practice I am not sure the government would be that uncomfortable shifting PCN resources to acute trusts and making practices even more vulnerable going forward.

The only real rationale for opting out of the PCN DES is a protest vote because of the lack of any negotiated outcome to this year’s contract, which is what the BMA seems to be pushing for.  But any rational analysis of the situation shows that it is in practices best interests to stay in the DES and to continue to be able to access its (growing) resources.  That said it doesn’t mean things shouldn’t change.  As I have argued previously, in many places PCNs are too distant from practices, and not run with enough attention being paid to the sustainability of practices in mind.  Now is the time not for practices to opt-out of the PCN DES, but rather to ensure that the PCN DES, a part of the national GP contract, is playing its part in ensuring the future sustainability of the service.

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