6
oct
0

A 3 point ICS Strategy for Local General Practice

Posted by Blogs, The General Practice BlogNo Comments

What is the plan for general practice within an Integrated Care System (ICS)?  It seems that for most the pressure of everyday life is far too much for GPs to be even thinking about this question, let along working out what the answer is.  But if general practice is to have a voice in the new system that is developing some form of plan is necessary.

For local general practice to have as big a voice as possible, and in the absence of any more tailored local solution, I would suggest the following as simple 3-point plan.

  1. Push for as much as possible to be devolved to place-based arrangements

ICSs are to work on two levels.  There is the overall ICS level, and a  number of local ‘place-based’ levels.  Each ICS has to decide how the local place based arrangements will work.  Specifically it has to decide whether to use the local arrangements as advisory within the wider ICS decision making, or whether to devolve decision-making authority to the local level.

The reality is that the influence of general practice will be much greater at a local level than at an ICS level.  An ICS Board only has to have one GP.  That GP will be appointed and in no way has to be representative of general practice.  However, at a local level the PCN Clinical Directors (CDs) are to represent general practice on the local place-based board.

It is difficult for general practice to establish consistent and shared views across practices.  The bigger the area, the harder the challenge of creating a shared view across practices is.  It makes sense to try and push decision making down to a local level, to give general practice the best chance of creating a consistent voice.

On the plus side the local councils will also be pushing for decision making to be devolved to a local level.  While there may be challenges ahead with the council within the place-based board now is a good time to ally with them to influence the ICS to establish a devolved decision making model.

  1. Create an Integrated Voice for General Practice at a Local Level

The challenge for general practice is to bring together all the constituent parts of general practice together to create a single, unified and therefore powerful voice.  This includes the individual practices, the PCNs, the local federation and the LMC.  For general practice to have influence with other system partners it needs to speak with one voice.  If it spends its time contradicting itself (e.g. the LMC speaking against the PCNs) then its voice can simply be ignored by system partners.

The areas that have had most success have done this at a borough or local level.  I wrote recently about what we can learn from the experiences these places have had.  Some ICSs are trying to push practices into creating a shared voice (or general practice ‘collaborative’) at ICS level.  It is hard enough making this work at a local level, and my strong view is that if you attempt to do this at too wide a level the internal arguments will be too difficult to overcome and the net result will be an extremely weak voice for general practice.  Far better to create local arrangements, and then ask the leaders of these local arrangements to come together and influence at an ICS level.

  1. Make Use of the Opportunity to Influence at Local Level

This strategy only works if once the ICS has agreed to devolve decision making to a local level that general practice actually takes the opportunity to influence decision making locally.  It means PCNs and practices working together to identify their priorities and to push these in the local meetings.  It means building relationships with local leaders and taking an active role in the working of the local place-based partnership meetings.

This is more challenging than it sounds.  PCN CDs are overwhelmed as it is with meetings and demands on their time.  The delivery responsibilities for PCNs have just been ramped up.  It is easy to ignore the local ICS partnership board as one more meeting that you don’t have time for.  But losing control of this now and giving it up to local authority and community providers who will be eager to take it would be a mistake that general practice could rue for a long time.

Not only does local general practice need to come together and create a single voice.  It needs to establish how it will discharge this voice and influence the local meetings.  This involves identifying one or two senior leaders who it will choose to build relationships with the other local leaders to represent general practice in discussions and at these meetings.

This three point strategy will only work if all elements are carried out.  If decision making is devolved but local general practice cannot agree with itself, its voice will still be weak or limited.  If it doesn’t attend the meetings or find a way of ensuring its views are adequately represented the same will apply.  However, if done well the rewards could be significant, as it is an opportunity for general practice to work with other providers and shape the provision of healthcare in their area.

29
sep
0

Why Extended Access is so Controversial

Posted by Blogs, The General Practice BlogNo Comments

There is a storm brewing in general practice.  Not unusually it relates to access, and more specifically extended access.  The ramifications are significant for PCNs more widely and the ability of general practice to be effective within local Integrated Care Systems.

What exactly then is the problem?

Right from the inception of PCNs it was announced that the funding for extended access would shift from the CCGs to the PCNs.  Originally this was planned for a year ago, but then this was delayed for unspecified covid-related reasons to April 2022.  It does look like it will happen this time round, especially because CCGs themselves will no longer exist at that point.

The current situation is that either local practices via a federation or an external provider deliver extended access.  This is not the same as out of hours, but covers 6.30–8pm on week days and 8am to 8pm at weekends.  Out of hours providers cover the 8pm to 8am period.

The issues can be broadly broken down as follows:

  • Where an external provider delivers the service there is often unhappiness with the quality of service provided, and many local GPs have a sense that a better service could be put in place, particularly given the amount of money on offer.

 

  • Extended access is funded at £6 per head of population. Given the requirements placed on the service, this feels generous to many GPs when compared to the core funding they receive.  We do not know whether this will be the funding level transferred to PCNs, or whether the service requirements will remain the same, but some practices believe it would make financial sense for extended access to be directly delivered by the practices in their PCN.

 

  • Many practices are at breaking point already. Regardless of the finances, there are many practices who are vehemently opposed to taking on extended access at a practice level.  The issue for these practices is that their staff cannot cope with the workload they have, and to then ask them to cover extended hours is untenable.  Those with longer memories view it as a step back to the pre-2004 days when GP practices were responsible for their own out of hours cover, and are passionately opposed to any such movement.

 

  • Federations use extended access funding to carry out far more than extended access. The relatively generous funding to date for extended access means that many GP federations have been able to build an infrastructure to support the delivery of at-scale general practice based on the extended access contract.  This has often included support for PCNs, delivery of vaccination services, delivery of resilience programmes (etc).  If the extended access contract is moved away from the federation by the PCNs then the whole at scale delivery capability for general practice that sits within the federation is put at risk.

The issue is hugely divisive because there are those practices who are adamant in their refusal to take it on, and practices and PCNs who are very keen.  Areas without a federation are already starting to feel forced into having to deliver this service, whereas areas with a federation are having to weigh up the impact on the federation as well as the impact on the PCN and its practices of any decisions they make.

The whole issue is unsurprisingly leading to increasing tension and animosity within general practice, just when it needs to be creating a united front.  The ongoing delays in the guidance from NHS England (it was due last year, then this summer, now it is due this autumn) are exacerbating the situation because without clarity on the requirements and the funding no one is in a position to make a final decision.

It is a controversial issue that is likely to become more divisive in the short term.  It falls to local general practice leaders to help navigate a way through this that works best for local practices and their populations, and not allow it become something that prevents general practice working together and having the united voice it so urgently needs within the emerging Integrated Care Systems.

22
sep
0

Making General Practice Effective within an ICS

Posted by Blogs, The General Practice BlogNo Comments

A key challenge for general practice operating within an Integrated Care System is how it establishes a single voice, and how it exerts influence given the strength and size of system partners such as acute trusts and local councils.  But already up and down the country we are starting to see local areas work through exactly how they will do this.

Establishing a unified voice is difficult for general practice. The independent contractor model, and 7000+ units of general practice, puts it at a distinct disadvantage compared to local providers.  Often there will be one acute trust, one council, one community and mental health provider and then anything between 5 and 10 PCNs and 40-50 individuals practices in any local ‘place-based’ area.  Across the ICS as a whole it is even worse, as there can be literally hundreds of practices, dozens of PCNs, but one (often merged) acute provider and one or maybe two community and mental health providers.

In this set up it is not hard to see how the unified voice of these single providers, with their hierarchical structures and large management teams, is going to be more powerful than that of general practice, given its relatively disparate nature and lack of any form of comparable management support.

But what we are now seeing in different parts of the country are attempts to bring the different parts of local general practice together to create some form of a unified voice.  There is superb example of this in Herefordshire, which we featured recently in an episode of the podcast.  There they have established what they term a ‘General Practice Leadership Team’, which comprises the federation leads, the PCN Clinical Directors, the LMC, and even the CCG Director of Primary Care.

This leadership team works through things together and agrees a single voice on issues, as well as providing a forum for general practice to meet with system partners where it is needed.

Other areas are equally bringing together the federation directors and the PCN CDs and the LMC into an overarching local leadership group for general practice.  Sometimes this is done within a federation infrastructure, and sometimes it is created separately to the local federation but with federation input.  Of course sometimes there is no federation, but I am yet to find an area without one who has actually started on this journey (do get in touch if you have!).

What early lessons can we learn from those areas who are taking the early steps along this journey?

The first is that there is no right way of doing it.  All of these systems rely on trust.  So the important thing is whether all those round the table are bought into the need to create a single voice for general practice, and whether the people leading the group are trusted.  Interestingly in Herefordshire the group is chaired by a manager, the Director of Strategy at the federation, but that works because she has the trust of those round the table, has good system relationships in place, and can take a neutral stance, i.e. is not seen as favouring their own practice/PCN over others.  More commonly there is a trusted GP at the helm.  What is clear is that it is trust in the person leading that is important, rather than their role or background.

The second is that system influence is a function of relationships, not just attendance at meetings.  What that means is that those leading need to be given the time to build relationships with the other system leaders.  While there is a benefit in distributed leadership (i.e. different individuals taking on different aspects of the system leadership requirements), there is also the need for a focal point and someone who is enabled to invest the time to build relationships with the individual local leaders of the other organisations.

The third is to be effective this type of system requires clarity on the roles of all concerned.  It is not an abdication of autonomy of the general practice organisations around the table to the group.  It is a place where decisions can be made about what requires a group decision, and what remains the responsibility of the PCN or federation or LMC (etc).  It requires clarity about if someone is purporting to speak in the name of the whole of local general practice exactly what process is in place for them to be able to do that, i.e. how is that individual engaging or briefed beforehand, what can they agree/not agree, and how do they feedback and implement any actions picked up.  And it requires clarity as to where delivery responsibility lies, as the group only provides a coordinating function (it is very rarely an entity in its own right).

The fourth is that such a system or infrastructure will take time to develop and become effective.  Trust (the key ingredient) has to build along the way.  And given how close we are to these new systems going live it is probably a journey that every area needs to be thinking through now as to how this is going to work locally.

This could be left in the ‘too difficult’ box (because of the size of the challenge!) but that then leaves general practice hugely exposed in the new system, with little hope of exerting effective influence on local decision making and resource allocation.  If there is no movement in this direction locally I would suggest the best starting place would be a conversation between the PCN CDs and the LMC to agree how to get started.

15
sep
0

Dos and Don’ts for the Next Phase of PCNs

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The recent PCN guidance signalled a new phase for Primary Care Networks.  In a recent blog I examined the guidance in some details.  The upshot, though, is that delivery expectations on PCNs will increase significantly from the start of October, and then again from March next year.

Covid has directly impacted on PCNs over the last 18 months.  Amongst other it postponed some of the delivery expectations to allow practices to deal with the pandemic and to roll out the vaccination programme.  Meanwhile the ARRS investment has continued.  Now the transition from set up to delivery is happening very quickly, instead of the more gradual shift originally intended.

This is significant for PCNs.  It means a move away from considering how to best use the ARRS funds to requiring a much stronger focus on delivery against the DES specifications, the IIF indicators, and any local schemes that may be in place.

So the set up phase of PCNs is effectively coming to a rather abrupt end, and we are entering a new delivery phase.  How should PCNs respond to this change?  Here are my top 3 ‘Dos and Don’ts’ for PCNs in making this transition.

DO

  1. Do be explicit about the link between PCN and Practice Work

Since 2019 the uplift in funding to the GP contract has come almost exclusively through PCNs.  This trend will continue for the next three years until 2024, and is highly likely to continue beyond that.  The funding and resources that will come to practices via PCNs will soon make up a key part of a practice’s income.  Participating in PCN delivery is not separate (and additional) to a practice’s core work; it is part of it.  For practices in a PCN to make the most of the PCN opportunity they need to work together, and make sure a commitment is in place from each practice to meet the delivery requirements.

  1. Do firm up the agreement between practices in relation to delivery

It is crunch time.  Some PCN targets can only be achieved if each practice plays its part.  But what happens if one practice does not meet the delivery requirements?  What if that means the whole PCN loses out financially? What are the consequences?  How will the PCN respond?  Will the practice have to recompense the other practices for any income lost? How will it work? It is really important practices within a PCN have a clear upfront agreement in place of exactly what the requirements in relation to delivery are, and what will happen if these are not met.  Without these in place life could become extremely difficult over the next few months.

  1. Do put management support in place

Many PCNs have some management support in place, but some still do not.  The latest guidance promises £43M for ‘PCN leadership and support’ this year.  If it is not already, ensuring delivery against all of the new requirements will be impossible for PCN CDs to do on their own from October, so use this funding to put some management support in place.

DON’T

  1. Don’t Change PCNs

Being in a PCN can cause relationships to fray, and working together can sometimes feel more difficult rather than easier over time.  But if you have got this far with your PCN configuration don’t be tempted to change it now.  Changing PCNs means doing all the start up work all over again, and frankly there is not the time to do this as well as meet all the delivery requirements.

  1. Don’t ignore the fact that a practice is not delivering

Conflict is difficult, and PCNs have been working hard to build relationships between its practices over the last two years.  But if a practice is not meeting its extended hours commitments or its care home requirements, and that is impacting the PCN as a whole, then it needs to be tackled.  Ignoring non-delivery now sends a message that non-delivery is ok to everyone, which in turn will make effective delivery across the increasing range of requirements almost impossible to achieve.

  1. Don’t waste your time in pointless meetings

The value of PCNs will ultimately come from their ability to make a difference to their local population.  It will not be determined by the number of system meetings that the PCN attends.  This phase for PCNs requires an internal focus to make sure they are each able to deliver effectively.  A PCN’s influence will increase if it can gain a reputation as one that can make change happen, versus one that attends a lot of meetings with little end product.

8
sep
0

What Next for General Practice Nursing?

Posted by Blogs, The General Practice BlogNo Comments

General Practice nursing has reached something of a hiatus: the ten point action plan published in 2017 has expired and as it stands there appears to be nothing new taking its place.  At the same time the Primary Care Networks (PCNs) dominating much of the general practice agenda make relatively little mention of the nursing workforce.  So where does this all leave general practice nursing?

At the time of the publication of the General Practice Forward View in 2016, along with the subsequent 10 point action plan for general practice nursing, there was a gentle optimism that the problems within the general practice nursing profession were finally being recognised, and action was being taken to resolve these.  But fast forward to five years later and it seems the situation remains critical.

While the numbers of nurses attracted into general practice has risen over the last few years (NHS Digital data reports just over 24,000 nurses in 2020 compared to c15,000 in 2015), the fundamental problems in relation to retention of these nurses remain.  The aging workforce, the lack of career opportunities, and the generally poor support for nurses all contribute to the retention challenge.  General practice nurses are funded via the core general practice contract, have no direct influence on the contract negotiations and are not part of agenda for change, and the inequity of pay this generates is the source of much frustration.

PCNs have not helped.  Many nurses are angered by the lack of mention of general practice nursing in the PCN documentation, in particular in relation to the additional roles coming in via the PCNs.  It makes already undervalued nurses feel even more underappreciated, while other professions brand new to the sector receive all the support and attention.

Nurses have provided the frontline of face to face care in many practices during the pandemic.  While many clinical staff were able to function through the use of remote consultations, it was often nurses who had to continue the face to face work such as immunisations and vaccinations, right at the time when the situation was at its worst.  The Queen’s Nursing Institute’s General Practice Nursing Report published last year includes many individual examples of this, and there is no doubt that many GPNs felt exposed to increased risk compared to other workers.

Where does all of this leave the profession now?   Ironically, the introduction of the other roles, and the challenges associated with this, has reinforced for many GPs the value of GPNs.  It is a source of frustration for GPs as much as the nurses that they cannot use the ARRS funding to strengthen this particular workforce.  Despite this, there should still be a place within PCNs for practices to consider how they are supporting their nurses alongside the other roles.

The nurses themselves also have a role to play.  Mel Lamb, a recent podcast guest, describes the need for a change in mindset from the nurses themselves to be more proactive about the opportunities that do exist, and to take more of a leadership voice in how general practice operates.  We have seen the emergence of the Institute of General Practice Management in the last year creating a national leadership voice for practice managers, and it does seem that a similar kind of unifying impetus is needed for GPNs.

National support and action is also required.  It is impossible to look at where we are now, review the progress made over the last five years and decide the job is done.  It cannot be left to the discretion of local areas to determine whether any more action is taken.  There has been some great work started via training hubs, federations and other organisations and these need to continue to be supported and funded, alongside a proper focus on how this critical staff group can be retained, to ensure any gains made are not lost in the next five years.

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