16
oct
0

PCNs versus Neighbourhoods

Posted by Blogs, The General Practice BlogNo Comments

With the new government coming to power, the collective action, and the lack of any real pointers as to what is to come in the existing, rolled-over contract there is a lot of uncertainty as to the future for general practice.  A key question is whether PCNs will continue.

However, we do know that the new government is very keen on what they term a “neighbourhood health service”.  For PCNs this brings hope, because they are the closest existing NHS structure to what might be meant by a neighbourhood, but at the same time uncertainty because the government rarely mention PCNs and do not seem to them as synonymous with neighbourhoods.

So what is a neighbourhood, and how are they different from PCNs?

There are some insights into this question in the NHS Confederation’s recent publication “Working Better Together in Neighbourhoods”.   This does acknowledge that neighbourhoods are difficult to define, and starts with the premise that the closest recognised structure to neighbourhoods is not PCNs but rather the Integrated Neighbourhood Teams outlined within the Fuller Report.  These teams bring together professionals from health and care providers as well as voluntary, community and social enterprise organisations – i.e. a much wider range of professionals than currently exist within PCNs.

The report, “supports the Darzi review findings that INTs, in a statutory context, are essential to health and care services being more proactive, preventative and person-centred. This requires organisations within neighbourhoods to be able to integrate their structures and relationships.”

The push, then, is very likely to be for PCNs to develop into Integrated Neighbourhood Teams (INTs), but not as loose collaborative constructs like PCNs but rather as a formal part of the NHS.  Exactly how this may happen is not something that is explicitly addressed by the report.

The NHS Confederation document goes even further and argues that neighbourhoods need to be more than the bringing together of local health and care providers into some form of statutory entity.  It emphasises the need for an active role for communities within neighbourhoods.  It argues that successful neighbourhood working exists “somewhere in the middle of a spectrum that ranges from wholly community-led to wholly statutory led”.

The report explains more about what it means by this, “INTs and related approaches to working with communities will need to align to, but are not the same thing as, community-led development… A PCN-led model may have a principal goal of expanding the ability of the practices to meet patient needs, whereas a community group may focus on building social capital and community connectedness.”

So while PCNs are owned and controlled by GP practices, neighbourhoods will not be.  According to the report they will encompass a range of local health and care providers and will need to be built in partnership with local communities.  The report ends up by recommending that the GP contract be reformed so that general practice can play a leading role in neighbourhood health models.  It also recommends that primary care resources should be aligned around neighbourhood priorities.

While the document has no formal status it is indicative of the direction of current thinking.  How this will play out remains to be seen but the implications are significant.  For general practice the independent contractor model may be more at risk than ever, and PCNs are likely to see a rapid evolution into one of the building blocks of this new neighbourhood health service.

9
oct
0

The Risks of Collective Action

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In his speech to the RCGP Secretary of State for Health Wes Streeting called again last week for general practice to end its collective action.  Should general practice simply ignore him and continue down the path it is currently on, and if it does what risks is it taking?

The new government is clearly keen to end the existing disputes with the NHS.  They have managed to come to a speedy resolution with both the junior doctors and the Consultants, and they are clearly keen to add GPs to this list.  Their belief is that the dispute general practice has is with the previous government, and that by meeting the recommendation of the DDRB and providing £82M to ensure the employment of newly qualified GPs, as well as stating that funding for primary and community care will rise as a percentage of total NHS spend every year for the next 10 years, they have done more than enough to at least be given a chance.

In his speech to the RCGP Wes Streeting instead asked for GPs “to work with us to rebuild the NHS together”.  He seems genuine enough, and so while I don’t think it was intended as a threat (i.e. if you don’t stop collective action then you won’t have the opportunity to work us), the voice of general practice is unlikely to be strong in the discussions as to what will end up in the 10 year plan if collective action continues.

Worse, the overall sense that general practice in its current form is “difficult to do business with” is reinforced by its seeming intransigence over collective action.  There is clearly a debate as to the future of the independent contractor model, and whether such a model is compatible with the government’s stated priority of shifting care from hospitals into the community.  A key part of the collective action is focusing only on core contract activity and stopping any work for the system, which of course will reinforce the view that it is having a core contract at all that is the problem.

That is not to say the collective action should necessarily be paused.  While the 6% uplift and the new ARRS contract for GPs are welcome, they do not end the challenges to practices caused by 3 years of disinvestment (and in the case of the scheme for new GPs will probably end up costing practices money).

While the government may want to do business with general practice, there has been no hint of any inclination by NHS England to do the same, who instead seem set on limiting any new money to the service (the failure to uplift the ARRS budget to accommodate the pay awards being the latest example).  The NHS is in dire financial straits, and general practice continues to be regarded as an easy option when it comes to making savings.  If the threat of collective action is taken away things could easily end up becoming even worse.

Collective action, as the GPC regularly point out, is a mechanism by which practices can start to control their workload given the cards that they have currently been dealt.  With no offer of additional in-year funding or support many practices feel that there is no alternative but to take matters into their own hands.

The problem is that the reasons to continue collective action are short term, and focus on what is happening now.  What is important it that the long terms risks general practice is taking by continuing collective action are understood – that it may alienate itself from discussions and reduce its ability to influence the forthcoming 10 year plan for the NHS (despite the key role that primary and community care will need to play in it), and that it may make fundamental change to the independent contractor model more likely as that becomes seen as the problem.  If collective action is to continue then these longer term risks need to be mitigated, to ensure that this short term measure does not end up inadvertently inflicting lasting damage on the profession.

2
oct
1

The Details of the Additional Role Reimbursement Scheme for GPs

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The PCN DES has been reissued to include the addition of GPs to the Additional Role Reimbursement Scheme.  This contains the details of the new £82M funding that the government previously announced for GPs to be added to the scheme.  What do the details mean for the difference this funding will be able to make?

The good news is that there are relatively few strings attached to the funding.  There were concerns that there would be a relatively tight specification on exactly what these new GPs could be employed to do, but PCNs have been given a relatively free hand in choosing how to make the most of these GPs once they are employed.

It is also good news that PCNs are not being asked to produce a baseline on how many GPs they had, to prove that any employed via this scheme are additional (as, you will no doubt recall, was the case with pharmacists).  The funding cannot be used to continue to fund someone already in post pre-October 2024, but that is more or less the limit of the additionality test.

The bad news is that any GP employed with this funding has to be within their first two years since qualification (at the point at which they start with the PCN).  If they are more than two years post-qualification then this funding cannot be used to employ them.  These GPs cannot be employed as locums, and must be employed or engaged on terms or conditions that are no less favourable than the model terms and conditions for salaried GPs (B.19.4).

This terms and conditions requirement means that there is no chance of PCNs being able to reduce the on-costs of the additional GPs, and raises the important question of what it means in terms of how much funding each PCN will receive.  PCNs will receive £1.303 per weighted population, which means that a PCN with a population of 50,000 will receive an indicative amount of £65k for the six remaining months of 24/25 (that can only be spent on these newly qualified GPs).

The (annual equivalent) maximum reimbursable amount per GP is £92,462 (£95,233 with London weighting).  This falls more or less at the mid-point of the NHS Employers current salaried GP range of £73,113-£110,300, but of course this doesn’t take into account on-costs.  If we assume 9 sessions per week and 28% on-costs it means the maximum reimbursable amount is just over £8,000 per session.

Unfortunately, the available newly qualified GPs are not evenly distributed across the country.  This level of funding is unlikely to be enough on its own to persuade them to move to areas that may already by under-doctored.  Equally where there is competition amongst local PCNs in areas where there are GPs it seems highly possible that PCNs limiting themselves to the maximum reimbursable amount may find it difficult to secure a GP, and may need to dip into (already overstretched) PCN coffers to do so successfully.

When £82M arrives nationally at a single point in time and can only be used for one specific purpose (employing newly qualified GPs) then demand is always likely to exceed supply and so it should not be a surprise if it leads to prices going up.  Good for the newly qualified GPs, bad for the practices.

Overall, the issue with the scheme is that it seems designed to support and help the newly qualified GPs by securing them employment, but not GP practices with the challenges they are facing.  The call for the profession had been that if there is no new funding they need to be able to use some of the ARRS funds for GPs (the more experienced the better) rather than additional roles.  What this does is still maintain the protection on the existing ARRS money, limit the employment of GPs to those who are newly qualified, and most likely create an additional drain on PCN funds.  Of course new money is welcome, but it feels like the challenges practices are experiencing are still neither understood nor being taken seriously at a national level.

25
sep
0

Does the Infrastructure Exist?

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The new government has been very clear in its desire to shift resources out of hospitals and into communities, to increase the focus on prevention, and to establish a “neighbourhood NHS”.  But the question we are very much left with, and one that seems to be at the heart of what the government is grappling with, is whether the infrastructure exists in primary and community care for this so-called “left-shift” to take place.

The parlous state of the general practice estate was highlighted by the Darzi report.  The government recognise there can’t be a wholesale shift of activity if there is neither the space nor the facilities for this activity to be carried out in.

Equally, the need for a new operating model was stressed.  Ever since the Darzi report was published with its promise of a greater share of NHS funding for primary and community care the government has been insistent that there will be no new money without reform.

PCNs and GP federations, despite being the place where practices work together to enable just the kind of shift the government has been looking for, have been largely ignored.  They hardly get a mention in the Darzi report, and while Mr Streeting has been keen to stress that independent GP practices will still have a role to play, he has been less forthcoming about PCNs.

We may have the first inkling as to why in the recent IPPR report.  This was reportedly warmly welcomed by Wes Streeting, and it calls for the government to, “Create Neighbourhood structures: PCNs are not working to put primary and community care in the lead of the NHS’ future. We need to found the neighbourhood NHS – by investing in a hub and spoke model of general practice, and by setting up Neighbourhood Care Providers to lead strategy, invest in population health and revitalise the NHS’ relationship with real communities.” (Summary report, p37)

This report argues that GP practices being outside of the NHS means they are rarely a priority for investment, encourages them to operate at small scale, creates a barrier between primary and secondary care, shifts too much risk onto GP partners, and makes the profession unpopular to junior doctors (Full report, p99).  It argues for a shift away from the “loosely federated partnerships” that are PCNs, and towards a model of what it terms “Neighbourhood Care Providers”, which are to be accompanied by Neighbourhood Health Centres requiring a capital outlay of £12.5bn(!) spread over 10 years.

The report ends up in more or less the exact same place the Fuller Report did when talking about Integrated Neighbourhood Teams, “NCPs could either be newly created or formed by existing community trusts, more advanced PCNs or multi-speciality community providers (MCPs). Over time these NCPs should take on the contracts for primary, mental health and community care.”  (Full report, p101).

The IPPR report is not a policy document.  But IPPR is a left-leaning think tank, and it was set up in the 1990s to “provide theoretical analysis for modernisers in the UK Labour Party”.  Given Labour’s manifesto pledge was to set up a neighbourhood health service, this report has the feel of one designed to provide ideas as to how this could be achieved, and it would not be a surprise to see at least some of this thinking appear in the forthcoming 10 year plan.

What all this means is that the policy question is not whether the independent contractor model is good or bad, but rather how the necessary infrastructure in the community can be developed to enable the desired shift of activity to occur.  This report raises the question of whether the independent contractor model is in fact a barrier to the development of this infrastructure.  This needs to be actively refuted, and what general practice should be doing (rather than setting itself against a government that has clearly stated it wants to invest in and support general practice) is come up with its own view of how this shift could be achieved in a way that builds on the core strengths of independent general practice rather than destroying it.

18
sep
0

What does the Darzi Report Mean for General Practice?

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Lord Darzi has carried out his “investigation” into the NHS, and recently published his findings.  It is a meaty tome at a 163 pages, but what does it mean for general practice?

Unlike some other NHS reports, general practice features heavily throughout, and is not added on as an afterthought.  In the summary letter the second issue highlighted (after the NHS not being able to keep its promises) is that people are struggling to see their GP:

“GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level. There are huge and unwarranted variations in the number of patients per GP, and shortages are particularly acute in deprived communities.”(Summary, 6)

This kind of positioning is not going to be followed by a lack of action.

Does this mean more money?  Well, there is a clear recognition that there has been a failure to invest in general practice, “We have underinvested in the community. We have almost 16 per cent fewer fully qualified GPs than other high income countries (OECD 19) relative to our population” (Summary, 13).

However, there are also criticisms of the GP contract, “the current GP standard contracts are complex and can mean that doing the right thing for patients can require doing the wrong thing for GP income. That cannot be right.” (5, 36).  And when it comes to primary care estate, “It is just as urgent to reform the capital framework for primary care as for the rest of the NHS.” (5, 37)

The idea that pervades the report when it comes to general practice is that it needs to be invested in but it also needs to change.  The basis for this change centres around the need for community based multidisciplinary team working.

In chapter 3, on quality of care in the NHS, when discussing long terms conditions it states, “As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace. GPs are expected to manage and coordinate increasingly complex care, but do not have the resources, infrastructure and authority that this requires.” (3, 32)

Again in Chapter 5, “People with two or more conditions (whose prevalence is growing over 6 per cent) may require care from different specialists and the expertise of GPs and others to understand the interactions between their conditions, treatments, and medicines. Since healthcare is organised around groups of professionals with similar skills (such as GP practices, mental health or community trusts, and hospitals), it requires organisations to work well together.” (5, 8)

The report calls this shift of resources out of hospitals and into the community a “left shift”.  However, the report is clear that such a shift must come alongside a change to the operating model, “Changing both the distribution of resources and the operating model to deliver integrated, preventative care closer to home will be strategic priorities of the NHS in the future because they are derived from the changing needs of the population.” (5, 21)

The report calls much of what has happened so far within integrated care systems as “collaboration”, but not “integration”.  It clarifies the difference between the two, “Collaboration and integration are often conflated, but they are not the same. Service or clinical integration is about a fundamental change in the way health services are organised for patients rather than the degree to which NHS organisations cooperate with one another as institutions.” (5, 23).  The report raises a concern that current collaborations are not effective and states that, “there is a real risk that they amount to displacement activity from the strategic priorities of delivering integrated, preventative care closer to home” (5, 25).

Primary Care Networks, interestingly, receive only one mention in passing in the entire report.  They are certainly not presented as the solution to the need for effective multidisciplinary team working.  So even though PCNs would seem to tailor perfectly with the Labour idea of a neighbourhood NHS, it may be that they are viewed more as “collaboration” than “integration”.

In his conclusions, the themes Darzi pulls out include these:

“Lock in the shift of care closer to home by hardwiring financial flows. General practice, mental health and community services will need to expand and adapt to the needs of those with long-term conditions whose prevalence is growing rapidly as the population age. Financial flows must lock-in this change irreversibly or it will not happen.

Simplify and innovate care delivery for a neighbourhood NHS. The best way to work as a team is to work in a team: we need to embrace new multidisciplinary models of care that bring together primary, community and mental health services.” (Conclusion, 6)

These two recommendations sit alongside each other.  So the good news is there will be new investment, but the bad news is that it will almost certainly come with a requirement for a whole new way of working.  What this will look like remains to be seen, but the government has been very keen indeed since the launch of this report to stress that any new investment will be accompanied by a requirement for reform.

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