10
nov
0

Is General Practice Making the Most of the Opportunity of PCNs?

Posted by Blogs, The General Practice BlogNo Comments

It is a difficult time for general practice right now. The pressures of workforce and workload are higher than ever, exacerbated by the media and their impact on patient expectations and overall morale.  How can general practice move forward?  How can it shift from the place that it is now into a more sustainable future?

In 2016 the GP Forward View, a 5 year “rescue package” for general practice, announced an extra £2.4bn for general practice by 2021.  This was then somewhat usurped in 2019 with the new 5 year GP contract that announced an additional £2.8bn for general practice by 2024.

What we have known for a while is that more resources on its own are never going to be enough for general practice.  We don’t feel £2.4bn better off than five years ago.  The reason for this is the growth in resources will never be able to keep up with the growth in patient demand and expectations.  There need to be changes alongside the resources.  These changes need to be in how we manage demand and how we organise ourselves.

Here we get into problems.  No one really likes change.  Look at how certain sections of the public and the media have reacted to changes to the management of demand in general practice where only those who actually need to be seen (as opposed to those who want to be) are seen face to face.  Whether the government likes it or not we will end up there, but it helpfully reinforces the point that no one likes change.

When you examine what options are available for changes in terms of how general practice organises itself (which we did in our 2016 book) they are broadly around staffing, operating at scale, using technology and working in partnership with other organisations.

This is where PCNs come in.  What stands out for me about PCNs is that they offer an opportunity for practices to be able to make virtually all of these changes, and to be able to do so in a way that protects the independent contractor model.  Prior to PCNs it was all about mergers and super practices, but what PCNs do is provide a construct that allows practices to access the benefits of scale while at the same time protecting their own individual identities.

But delivering the potential benefits does not happen by itself, or as a function of signing up to the PCN DES.  It requires practices within a PCN to commit to using the PCN construct to drive change in the way the practices operate to realise the benefits.  Change does not become easy because you call it a PCN.  It remains difficult, but what PCNs provide is a framework for practices to use if they choose to do so (in addition to providing a huge source of resources – £1.8bn of the additional £2.8bn announced in 2019 is coming via PCNs).

I have no idea whether this was the original idea behind PCNs.  I suspect it wasn’t.  Certainly the contractual nature of PCNs, the tick box style of the IIF, the push to recruit more and more new roles with hardly any support for transformation alongside these roles, and the continual attempts by the system to hijack the PCN agenda are not conducive to practice transformation.  But at their core PCNs do provide practices with the chance to broaden their staffing model to reduce the pressure on the GPs and to build relationships with other practices and other organisations to create shared service models that work better for everyone.

However, at present it feels like PCNs are an opportunity for general practice that is not really being grasped.  Many practices choose to keep PCNs at arm’s length.  The BMA is trying to use PCNs as a mechanism for pressuring government and NHSE.  Others want to use PCNs for their own ends.  But PCNs are a huge, well-resourced opportunity to make change that can be a huge force for good and for creating a positive future for practices.  Practices just need to choose to take it.

3
nov
0

Should PCNs be Political Footballs?

Posted by Blogs, The General Practice BlogNo Comments

Two weeks ago the BMA reported that it had rejected what it terms “the government’s rescue package” and that it was to take a ballot with the profession on industrial action.

The specific motion passed by the GP Committee contained two clauses directly pertaining to PCNs. It:

ii. calls on all practices in England to pause all ARRS recruitment and to disengage from the demands of the PCN DES
iv. calls on all practices in England to submit undated resignations from the PCN DES to be held by their LMCs, only to be issued on the condition that submissions by a critical mass of more than 50% of eligible practices is received

What does this mean for PCNs?  There are effectively three requests being made of practices in relation to PCNs.  The first is to pause ARRS recruitment.  Unfortunately ARRS recruitment is the one part of the PCN DES that many practices consider to be value adding.  Whilst there are some whose primary concern is the clinical supervision, line management and estates challenges these roles can create, increasingly practices are able to realise the benefits of these additional staff on their workload and outcomes for their populations.

It is hard to understand how sending a message to practices and PCNs to stop recruitment into these roles, the one thing that is helping with overall workload, is helpful in the current context.  Do we think that collective pausing of recruitment for a few weeks or months will influence the government/NHS England?  The downside of the suggestion seems far more detrimental than any potential upside.

The second is the call for practices to disengage from the demands of the PCN DES.  There is an anger amongst many that the delivery expectations on PCNs have been ramped up so steeply from October 1st.  The number of IIF indicators (the ‘PCN QOF’) has gone up from 6 to 19 for the last six months of the year, along with a requirement to deliver against two additional DES specifications (health inequalities and CVD prevention and diagnosis).  Disengaging will, however, potentially cost the practices of an average PCN £120k (what they could earn through delivery of the IIF indicators, which are also linked to the delivery of the two specifications).

The third is the submission of undated resignations from the PCN DES by practices. This suggests that the reason practices participate in the PCN DES is because they want to support the government’s/NHS’s desire for PCNs to exist.  In reality there are two reasons.  The first is that PCNs make sense financially for practices, and the second is that practices believe that by working together as a PCN they can improve outcomes for patients.  While the initial decision to sign up was probably more for the former reason, as time has gone by more practices believe they can make a difference through their PCN.

The request, then, is for practices to sacrifice the benefits they receive and believe can be achieved for their patients in order to derail the wider national plan in relation to PCNs, to build influence in the debate on the issues of concern (i.e. the failure to address the crisis in general practice, the recently published plan around access, the GP earnings declarations, and for GPs to oversee the Covid vaccination exemption process).

I understand the desire for greater negotiating power.  The cost, however, falls on PCNs themselves.  While PCNs have been working hard to build trust across their practices, to create ways of working that benefit all, and to make a difference both to practice sustainability and patient outcomes, the effect of something like this is to set the whole thing back.  It makes it easier for the practices that have never really engaged to not do so, and makes it even more difficult for those who have been working hard to realise the benefits of joint working, because now the spectre of mass resignation can sit as a rationale for inaction.

So is it worth it?  Is the threat around PCNs worth the problems this causes to practices?  The Guardian reported that the BMA had won “significant concessions” from NHS England following its threat of potential industrial action.  These included the plan to publish ‘league tables’ – showing what proportion of appointments were in person – had been abandoned, along with specific targets.  However, the organisation seemingly responsible for setting policy in relation to general practice, the Daily Mail, reported that the Department of Health had moved quickly to insist it had made no concession to doctors’ unions, and that it would press ahead with measures to publish surgery-level data on face-to-face appointments.

Time will tell how this will all play out.  I fully support the push back by general practice to the NHS England paper on access, which was the NHS operating at its very worst.  However, I worry that not enough thought has been put into the consequences of conflating PCNs into a dispute that is not actually about PCNs.  Doing so is effectively self-harming for the service, and in particular it has left those in PCN Clinical Director roles, who are arguably doing the most for general practice right now, in a very difficult position indeed.

27
oct
0

GUEST BLOG: Dr Rachel Morris – 3 Conversations You Should Be Having With Your Overwhelmed Teams Right Now

Posted by Blogs, The General Practice BlogNo Comments

Many of our team members in Primary Care are feeling battered and bruised by the tone and content of what’s coming out from on high, and everything going on in the media. As a leader you may feel frustrated and angry yourself, and you may be wondering just what you can do to help everyone keep on going through these really tricky times.

There are three key questions which will help you and your team to take stock of what you can do about the situation, work out what you should be prioritising and reduce some of the stress and anger about what’s going on.

 

What can I control?

The first question is all about what is in your power to change, and what’s not.

In any of life’s challenges, there are things which we worry about which we simply can’t do anything about (for example, rising COVID rates, government policy, the national shortage of GPs). Dwelling on these things is a waste of precious time and effort as there is literally NOTHING that you can do to change them.

A far more productive way to spend your time and mental energy is to ask yourself ‘what is in my control right now?’. A simple way of doing this is to do the ‘Zone of Power’ exercise.

Get a sheet of A4 paper, draw a circle – this is your zone of power. Outside the circle list all those things you are not in control of, and inside the circle list all the things which you ARE in control of, and the options and choices which you have. You may not like all of these options and choices and you may feel frustrated about the consequences of some of these choices, but you will feel more powerful and productive by focussing on what you CAN do rather than what you can’t.

The key to this exercise is learning to ACCEPT the things you can’t change and find the COURAGE to change the things you can (this will also help you with the WISDOM to know the difference – sound familiar?!).

Use this question with your team members whenever any of you feel stuck, to work out what your next actions could be.

 

Where is your focus?

The second question helps teams get super clear about what your priorities should be right now.

Many teams in primary care are feeling overwhelmed and exhausted. There are too many things to do and not enough time or staff to do them. But do you know exactly what these things are? Have you had a conversation about what you should be prioritising as a team, as a practice, as a PCN?

So often, we see team members with different priorities going in different directions which causes confusion and overwhelm as no one really knows which is the most important priority, and what they can drop for now. Without this conversation, the stuff that’s urgent will always crowd out the stuff that’s really important but perhaps not urgent – yet, such as team development, sorting out workflows, delegation and staff training.

Getting clear on what three things you will be focussing on as a team in the next week, month and year will help reduce overwhelm, create some mental headspace, and make sure you’re all laser focussed on the same things.

 

What story are you telling?

As patient demand and expectation seem to grow every week and negative stories in the media threaten to kill our morale stone dead, it’s helpful to ask yourself ‘What is the story in my head’ about the things that are bothering you.

When patients are rude and demanding, do we tell ourselves that’s because they are completely unreasonable, that they all hate us and that we’re doing a terrible job? Or do we recognise the truth – that patients may be frightened and worried about themselves (after all, we are going through an incredibly traumatic time as a planet), they may be frustrated that they can’t get exactly what they want instantly (in a world of Amazon Prime and Netflix).

Do we tell ourselves that we are failing and not good enough? Or that Primary Care is doing an AMAZING job in the face of huge challenges, and that we are doing our absolute best through difficult times?

Are we telling ourselves that it’s us vs “them”. Or that we are all actually on the same side, wanting a properly funded, safe and efficient primary care service in which staff AND patients are thriving?

Are we telling ourselves that we ‘have’ to do it all, can’t take any time out or that saying ‘no’ makes us a bad person? Or are we recognising the truth that it’s only by putting our own oxygen mask on first, recognising our limits, and taking time to rest and recharge that we will do our best work?

The stories we tell ourselves create feelings which lead to actions. The negative stories we tell can only lead to stress, disillusionment and often keep us stuck and frustrated. By re-framing what we choose to believe (but not denying the reality of the difficulties) we can start to change our feelings and actions and reduce the stress and levels of burnout we experience.

These are simple questions, but they are not easy. They require a degree of self-examination and recognition of some difficult truths BUT if you start to ask them with an open mind, kindness and a large helping of self-compassion they may just help you and your team make better decisions, take control of your workload, and start to enjoy what you do again.

Our Resilient Team Academy online membership for leaders in health and social care provides conversations canvasses, coaching demos, video training modules, bite size team building videos and deep dive live webinars to help leaders and managers have these important conversations and support their teams care for resilience, wellbeing and productivity. Doors to the RTA are open right now and we have discounted packages for Ockham Healthcare subscribers, and packages for PCNs and other organisations. Find out more here or get in contact with Ben (ben@ockham.healthcare).

You may also be interested in watching a recording of a recent webinar that Ben and I did, ‘How to support your team through the new ways of working in primary care, without burning out yourself.’ You can find it here.

20
oct
0

A Reminder of the Value of Independent Contractor Status

Posted by Blogs, The General Practice BlogNo Comments

Last week NHS England published, “Our Plan for Improving Access for Patients and Supporting General Practice”.  It is a document that lacks coherence, and is clearly a performance management document that has then been added to to try and make it ‘acceptable’ to the profession (e.g. add “and supporting general practice” to the title).  This hasn’t worked, and, understandably, it has created an angry reaction across the general practice.

In the NHS direct performance management like this has been common for a number of years.  Statutory NHS bodies such as Acute trusts, Community Trusts, CCGs (etc) receive edicts like this that demand certain actions and delivery on a reasonable regular basis.  These are then reinforced by senior leaders not achieving the targets being summoned to local then regional then even national performance meetings.  There was a time in the not too distant past when acute trust chief executives not meeting the 4 hour A&E target were being summoned to meetings with the then Secretary of State Jeremy Hunt.

This style of performance management is a particularly unpleasant side of the NHS.  It comes because those in the highest positions of the NHS have to demonstrate they have levers they can pull to make things happen on the ground, when they themselves are under pressure.  We have a new Secretary of State and a new NHS Chief Executive, and the bigger worry is that this is just the first taste of what life is going to be like under this new regime.

But if nothing else, the document is a timely reminder of the benefit of the independent contractor status that general practice enjoys.  The reality is that the Secretary of State cannot directly tell GPs what to do, or instruct how they should behave, in the same way that he can with NHS Chief Executives and senior leaders.

Whilst the document might feel like direct performance management (it is designed to), it is in fact an instruction for how NHS staff that are under the direct control of NHS England are to manage the contract they have with general practice.  They are the ones who are to submit returns by the 28th October, not practices themselves.  For general practice, its responsibility lies in making sure it delivers against the contract it has signed up to, nothing more.

For those who have not read the document (and it is not a read I would recommend), it essentially outlines a series of measures that it will introduce to try and increase the number of face to face appointments GPs hold with their patients.  They will use the data practices are now submitting to publish waiting times at practice level, and send a ‘hit squad’ into the practices with the longest waits.  The NHS is asked to compile a list of practices where the number of appointments is lower than pre-pandemic levels, of the 20% of local practices with lowest level of face to face appointments and with the most significant level of 111 calls in hours and A&E attendances compared to expected, and of where concerns have been raised with CQC and others.

The NHS is then to use this data to create an overall list (by 28th Oct) of local practices where “it will be taking immediate further steps to support improved access” (43).  These actions are to include “partnering with other practices, federations or PCNs”, and “contract sanctions and enforcement” (45).

Pretty grim stuff.  It is effectively an instruction for commissioners to use any contractual lever they can to make practices see more patients face to face.  They themselves will be directly performance managed on this, as they are “required to produce a fortnightly updated report for their region” (48).

For GP practices the best thing to do is simply ignore it.  As long as you are happy with the balance of remote to face to face appointments in your own practice and are confident you are meeting your contractual requirements, then don’t do anything.  The worst thing that could happen would be for this approach to be effective, because it would encourage the new national NHS leadership regime to do more of the same in future.  Practices have enough on their plate to content with right now, so let commissioners manage the flak that comes from above.  The good ones do this regularly and they do it well.

If general practice was part of the NHS (as opposed to an independent contractor) it would be having to manage this itself.   Independent contractor status is hugely valuable, and one general practice would do well to hold on to as long as it can.

13
oct
0

What do ICSs and PCNs mean for GP Practices?

Posted by Blogs, The General Practice BlogNo Comments

There is so much going on in general practice right now, and the workload pressure is so great, that it is easy to take a head down approach to everything that is going on outside the practice.  But the landscape around practices is shifting.  What do these changes mean for individual practices?

The big change is the introduction of Integrated Care Systems (ICSs).  This change is one that most practices are largely ignoring, but one that has significant implications for practices.

One of the reasons there is little interest shown by practices is because it is a change that is rarely clearly explained.  At its most simple the way the NHS is being organised will no longer be through a separation between purchasers (or commissioners) and providers.  Instead providers will directly work together to agree how care should be delivered, what the pathways should look like, and how the money should be spent.

In practical terms, CCGs will cease to exist from March next year, and they will be replaced by new NHS ICS bodies.  These role of these organisations is essentially to enable the joint working between providers that lies at the heart of the new system.  As a result all provider organisations are represented on the Boards of the new NHS ICS bodies.

ICSs will function on two levels.  There will be the whole-ICS level, where broader strategy decisions will be taken, but then also at local levels within the ICS area.  This local level is what is being referred to as the ‘place-based’ arrangements.  This will generally be the local area or borough that general practice has been part of for many years.

In most ICSs much of the decision making, including resource allocation, will be devolved to these local areas.  This will include funding for any local enhanced services/local incentive schemes for general practice.

At the heart of integrating care within a local area lies Primary Care Networks.  These were created not in splendid isolation from the rest of the system, but with the emerging ICS explicitly in mind.  The role of PCNs within the new system is to create seamless care for physical and mental health across primary and community care, to enable care to be delivered as close to home as possible, to create seamless pathways across primary and secondary care, to strengthen the focus on prevention and anticipatory care, and to support people to care for themselves.  The PCN is the core building block of the new integrated care system.

All of the work that PCNs have been asked to do so far (primarily via the PCN DES) has been with this in mind.  It underpins the specifications that have been developed within the PCN DES, and the indicators within the Investment and Impact Fund (IIF).

The asks and requirements so far on PCNs are only the beginning.  They will inevitably grow, and increasingly these will come from the local place-based Board of the new ICS (i.e. the one that sits at a local level), as opposed to nationally via the PCN DES.

When PCNs were announced as part of a 5 year contract for general practice in 2019 the funding split was as follows: £1bn extra to come via the core contract, £1.8bn to come into general practice via PCNs.  The more recent uplift in ARRS funds to cover 100% of salaries from 70% means the split in reality is more like £1bn to £2bn.  Most new general practice funding is already coming via PCNs.

But PCNs are only just getting started.  The ICSs do not become statutory bodies until April next year, when we will already be 3 years into the 5 year GP contract, with only 2 years remaining.  What will happen then?  Most (if not all) of the local enhanced service contracts from the ICS place-based board will come at a PCN not practice level.  The differential in funding growth after 2024 if anything is likely to be greater than from this 5 year agreement (i.e. the vast majority of resources coming into general practices will be via PCNs rather than via the core contract), because the foundation the whole new system is being built on is PCNs.

All of this means there are two really important things practices need to be doing now.  The first is to start treating the funding and resources the practice receives via the PCN as part of its core resource, and not as an optional extra separate from the ‘real’ business of the practice.  Investment into general practice is coming via PCNs, and so practices that try and sustain themselves into the medium term on core contract income alone are going to find life extremely difficult.  This may in turn have consequences for how practices choose to interact with their own PCN (a topic I will return to in a future blog).

The second is that practices must ensure that their PCN is directly engaged in the Board and leadership arrangements of the local-place based Board of the ICS.  I know the level of meeting requests in relation to the system and ICSs is bewildering at present, and can feel like a waste of time, but the one ICS meeting that PCNs must prioritise is this local place-based Board.  Each PCN has a seat on this Board to represent local general practice, and because this Board will have such a strong influence on how care is organised locally, and how resources are apportioned, it is critical PCNs take up this seat and do not leave it empty.

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