22
jul
0

Go Back to the Purpose

Posted by Blogs, The General Practice BlogNo Comments

We are a year down the line with PCNs.  Recent months have been overshadowed by covid, but there were significant PCN developments in that period.  In particular, the agreement by NHS England to pay 100% rather than 70% cost of the new roles, the rowing back of the service specifications so that now only three (relatively light) specifications need to be delivered this year, and the sign up to the 2020/21 PCN DES by almost all practices.

Last year I don’t think it is unreasonable to say a number of practices, and even whole PCNs, took a ‘wait and see’ attitude towards PCNs.  It was a case of cautious sign up without making any significant commitment.  But now practices are in a whole new position – the role reimbursement scheme funding is significant, the delivery requirement is greater this year, and the extended access funding is around the corner (April next year).  The relative importance, particularly financial, of PCNs to practices is starting to feel different, and so the attitude of practices towards PCNs is beginning to change.

What we are starting to see (understandably) in some areas as a result of this is more unrest within PCNs.  The move from practices taking a relatively passive attitude to one that is more active is inevitably starting to create friction.

This is primarily because GPs and practices often want different things from the PCN.  Should the PCN appoint first contact physiotherapists or more pharmacists?  Should the PCN spend its £1.50 on management support or retain as much of that money as possible for practices?  Should the PCN use the local federation or should it manage its own finances and employment?  There are often different answers to these (and similar) questions within the members of a single PCN.  Moving forward can be difficult.

So how does a PCN move forward in this situation, where practices seem to have differing views on nearly every issue?

The key priority here for PCNs is to work on a shared purpose for the PCN across member practices.  Even if PCNs did this in the early days it may be time now to revisit this given how the landscape has started to shift.  Once there is a clear, shared purpose this can be used as the framework for decision making by the PCN.

Easier said than done.  How exactly do practices develop a shared purpose?  How can practices agree what they want the PCN to achieve?  The key part of this is taking time to sit down together and for each practice to share what they want from the PCN (what we assume is often different to the reality), and then work hard to identify where the common ground lies.

This process may take some time.  The key is to create a framework within which the practices can make decisions together, and criteria to assess any decision against.  If the practices, for example, want the PCN to reduce practice workload, increase the voice of general practice, and improve outcomes for the local frail elderly population, these can become the criteria for assessing any decisions against.  But this will only work if all the practices are agreed and sign up to the framework in the first place, which is why it takes time.

A shared, agreed purpose will not end debates and arguments within a PCN.  There are very few PCNs where the practices agree on everything.  But as the responsibility, funding and influence of PCNs grows, the importance of having a clear direction and a framework to make decisions and settle disputes is greater than ever.

15
jul
0

3 Ways to Attract New Roles to your PCN

Posted by Blogs, The General Practice BlogNo Comments

There is a recruitment challenge facing PCNs this year.  There are over 1,200 PCNs, and each PCN has an average budget of £344,000 to spend on new roles.  This converts to more than 7 roles each, and if the time lag is built in (i.e. most of these roles are not yet in post, despite it being July) it could mean PCNs are recruiting to over 10 roles each.

That means there are potentially over 12,000 new roles being advertised by PCNs all at more or less the same time.  That number of viable candidates does not exist, and so the question facing PCNs is why would potential candidates choose their PCN over another?

The nature of the Additional Role Reimbursement Scheme (ARRS) means that the level of funding available to PCNs for the new roles is fixed, so what is unlikely to happen is that the result will be price competition.  PCNs are not going to offer more money to attract the best candidates.

So how can PCNs differentiate themselves?  This might not be as difficult as it at first appears.  Below are three simple steps a PCN can take to give themselves an edge over the competition.

1.Plan the Role in Advance. PCNs are not experienced employers.  The most likely scenario is that most PCNs will do the work as it arises.  That is to say they will first of all advertise the posts and make offers to the best candidate, but only then work out where the role will be based, how it will be managed, and how it will be supported.  Some may identify exactly what work the new role will undertake in advance, but others will only work this out once the new person is in post.

So if a PCN works out in advance both how the post will operate in practice, and how the role will be supported, it is likely to have a huge advantage over many other PCNs.  This means working out upfront where the role will be based, where the clinical work will take place, who will be the line manager, and who will provide professional support.  It means thinking through the mentoring, coaching, education, and personal development support that will enable the new postholder to be successful in their new role.

These things will have to be worked out anyway.  But a PCN that does this before it starts recruiting, and can provide this information as part of its campaign, will be much more attractive to potential candidates than one that plans to wait until the successful candidate takes up post.

 

2.Recruit a Team not just Individuals. Working for the first time in general practice can be daunting for candidates.  Many PCNs will recruit to each of the roles individually.  But if a PCN, or even a groups of PCNs, is recruiting (for example) a team of pharmacists or a team of physician associates, and builds team development and peer support into its offer, it is likely to have an edge.  The postholder knowing they wont be entering this new environment alone, but doing so as part of a team, makes taking on the new role less of a risky proposition.

 

3.Make recruitment personal. Finally, the recruitment campaign itself is an opportunity for PCNs to differentiate themselves.  If PCNs can offer an online platform which provides information about the PCNs and the local area, practices, opportunities and challenges, it is likely to have the edge on many other PCNs.  Even better if it can create a personal connection, e.g. a short video from a GP within the PCN talking about why the role is important, or from a named contact who seems friendly and approachable.

While the bad news is competition is likely to be fierce for the new roles, the good news is that with a little thought and effort your PCN could still be able to attract the best candidates.

8
jul
0

Lessons from AccuRx: Resist the urge to control

Posted by Blogs, The General Practice BlogNo Comments

A few weeks ago I wrote about how AccuRx had changed general practice over the course of a single weekend.  What can we learn from the achievements of a relatively small company like AccuRx, in contrast to the traditional ways of working in the NHS?

The most striking feature of the way AccuRx work is that they do not try and control how the innovation they create is used.  Their belief is that if you prescribe how something is to be used, you actually prevent innovation.

The core AccuRx product is the text messaging service.  They linked the service with the individual patient and their record, but didn’t prescribe how or when the service was to be used.  When practices were working out how to see potential covid patients face to face, some put signs in the car parks for patients to wait in their cars until they received a text message when they were ready to be seen.  Not a way of using the product the company could ever have foreseen!  Innovation in the use of the product came from the GPs and the practices, not from the company.

Equally with the video consultations, practices sent the link for the call to a family member who could interpret for the patient when they didn’t speak English.  In hospitals, it was used to enable virtual visits by relatives not able to visit in person.  Innovation was generated by front line staff, enabled by the initial development.

By resisting the urge to control and dictate how the change was to be used, far more innovation has developed as a result.

In general practice local teams in many parts of the country were allowed to work out how to respond to covid.  “Hot hubs” and the like were developed and locally tailored and implemented in days and weeks.  Without central control, frontline innovation prospered.

This is in contrast, of course, to how we normally introduce change in the NHS.  The urge always is to control.  Trusting front line staff to innovate feels risky because it cannot be predicted.  So what we do is insist on business cases that detail not only the change to be introduced, but exactly how it is be used and implemented, and the predicted impact that will result from the prescribed changed.  The more we control the change, the less risk we feel, but at the same time the more we suppress any wider innovation.

Let’s take PCNs as an example.  The basic change is to enable practices to work together and with local partners to improve outcomes for local populations.  But as an NHS we can’t leave it at that, and allow practices to use the change and innovate locally.  The urge to control is too great.  So instead we have template legal network agreements, detailed service specifications (remember the December drafts?), and maturity matrices.  The NHS attempts to control how PCN will operate, what they will do, and the way in which they will develop.

Resisting the urge to control is very difficult in the NHS.  Senior staff are consistently reminded that they are “accountable”.  The pressure to minimise and control any financial risk is immense, and leaves little room for trusting local staff and teams to innovate.  But the lesson from the success of AccuRx is that less control is exactly what is required to foster greater innovation.

1
jul
0

The opportunity of the additional roles for GP practices

Posted by Blogs, The General Practice BlogNo Comments

I wonder whether in the all the complexities of the additional role reimbursement scheme (ARRS), the underlying potential value of the new roles to GP practices is being lost.  Are we taking on the new roles so that we can make sure the needs of the PCN DES specification are met, or because the money is there, or because they are part of our strategy to create a sustainable future for our practice?

Just a reminder – despite all the promises of 5,000 (now 6,000) new GPs, and the increases in numbers of GPs entering training, the total number of wte GPs remains (at best) stubbornly static.  In the meantime the workload continues to rise.  While there are pockets of the country that can attract new GPs and do not have a GP recruitment problem, the majority do.  It is no surprise, then, that workload persists as the greatest challenge for the under-manned GP workforce trying to keep up with the growing demand.

If there are no new GPs available, it does seem to make sense to use different roles.  It makes sense from a straight workload perspective, providing much needed assistance to the overall workload problem.  It also makes sense from a financial perspective, as the new roles are generally cheaper than employing GPs, and a lot cheaper than paying for locums.

Life, however, is never that simple.  Resistance comes primarily from the mindset that the idea of the new roles is to allow lesser trained, lower paid clinical professionals to carry out the work of a GP.  It can feel to GP partners when presented with the option of new roles is that the ask is for under-qualified staff to undertake work that requires the skills and training of a GP.  The question appears to be one of whether the practice will sacrifice clinical quality for the sake of financial sustainability and a more manageable workload.

But those practices that have introduced new roles successfully have not used this mindset.  Instead, they have asked what parts of the practice work can be carried out more effectively by a different professional than by a GP.  For example, many practices that have introduced a first contact physiotherapist have found an increase in the quality of the relevant practice referrals to secondary care, to physiotherapy and indeed to self-care.  The same with pharmacists and medication reviews, link workers and meeting the social needs of patients, etc etc.

Ultimately, the aim of the practice is to identify how it can meet the challenge the new profile of demand presents, and consider how it can re-shape the way it meets that demand using the skills, experience and expertise of different clinical staff, so that it can make best use of the available (finite) GP time that it does have.

The opportunity of the PCN additional role funding is that these roles come fully reimbursed.  So not only can the practices in a PCN obtain the new roles they need, they can get them for free, or for whatever minimal contribution is required on top of the ARRS reimbursement.

It is a tremendous opportunity for practices.  I understand practices will have to deal with sharing the roles with other practices, and that the PCN specifications do provide demands on the time of the new clinical staff.  I understand that changing the way the practice operates to make the most of the new roles can be difficult and uncomfortable.  But this could still be a game changer for practices.  It is a chance to put the practice workforce in place that is needed to make the workload sustainable, in a way that it hasn’t been for many years.  I just hope practices work their own way through the challenges and grab this fantastic opportunity with both hands.

24
jun
0

The Future of Federations

Posted by Blogs, The General Practice BlogNo Comments

What is the future of GP federations?  Do they have one, or does the emergence of PCNs mean that the days of GP federations are essentially over?

The best place to start when searching for answers to questions like these in the NHS is generally the wider policy context, and this is no exception.  The existing set of GP federations can be by and large split into two categories.  The first set of federations formed in c2007 at the height of the commissioner/provider split, when ‘world class commissioning’ was a thing, and when a primary care provider vehicle was needed for the delivery of services in primary care.

The second set of federations formed 10 years later in c2017 in response to the extended access funding that was made available to general practice and in response to the increasing pressure that general practice was finding itself under.  Funded through the delivery of the access hubs, federations were able to play a wider role in supporting individual member practices.

But the end of the commissioner/provider split was formally (if not explicitly) announced by the publication of the Long Term Plan in January 2019.  It signalled instead a shift to integration.  System Transformation Plans (STPs) were to be implemented and Integrated Care Systems (ICS) developed.

Over the last 30 years a range of GP commissioning organisations have all come and gone, from GP fundholding, through primary care groups and practice based commissioning organisations, right up to the current embodiment as CCGs.  These are in terminal decline, as the NHS moves to replace the legacy of commissioning organisations with the new integrated arrangements.

The new, non-commissioning, integrated entity for general practice are Primary Care Networks (PCNs).  First mentioned in the Long Term Plan published at the start of 2019, they are described as the enabler of “fully integrated community based health care”.

Without a commissioner/provider split, and with the establishment of PCNs as the statutory (or as close to statutory as can be achieved with a set of independent contractors) integrated community provider, it is not clear what role a separate primary care provider like a federation can play.

So far existing federations have been able to co-exist with PCNs, primarily by using the funding in their extended access contracts.  But the funding for extended access shifts to PCNs next year.  While federations will struggle to replace the lost income, PCNs will continue to grow and develop as integrated community providers, with nationally mandated funding streams alongside additional local ones.

It will be tough for federations to continue to exist in isolation from PCNs.  PCNs mean there is no need for a separate provider arm of general practice within an integrated care model, because PCNs are that provider arm.  In the world of integrated care, without the commissioner/provider split, where does an independent provider like a federation receive its funding from?

The future of federations, if there is to be one, can only lie as an enabler of PCNs.  The real barrier to progress for many PCNs is their size, and by working together through a federation they can move faster and more effectively than they can on their own.  Federations could take on delivery of extended access, and indeed of a range of PCN delivery requirements, but only if the PCNs want them to do so.

Federations are currently viable as a result of the provider contracts that they hold.  As integrated care develops, these contracts will shift into the realms of PCNs and the joint working between the statutory providers.  Crunch time is coming soon with the shift of the extended access contracts, and it is hard to see federations surviving it if they are not built on joint working between PCNs.

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