The Grass isn’t Greener

One of the questions I am most regularly asked is why I am so supportive of the independent contractor model of general practice.  Wouldn’t life be easier and simpler for GP partners if they were free to operate as clinicians, without the almost full time distraction of trying to run a small business?

For many the grass does look particularly green on the other side of the fence, where GPs as part of NHS organisations could work reasonable hours, take annual and sick leave like any other employee, and be free from all the stresses of income, cash, staff, property, and unreasonable partners.  Life looks like it would be so much simpler.

Why, then, do we prize the independent contractor model so highly?  Well, as with any situation where we are looking to move away from problems instead of towards something we want, life on the other side will always contain its own set of (albeit different) problems.

Peter Muchie summed it up really well when he described his own experience of making this transition,

“And then I surrendered my independent contractor status to become a salaried employee with an NHS out-of-hours service. To me this now equates to a surrender of power and the right to self-determination. I can no longer organise my work to best meet competing demands. I can no longer negotiate with equal partners, but must accept the impositions of a cost-cutting management which seems to work toward the lowest common denominator. I can no longer decide what to accept and reject…

I no longer have total freedom to develop my skills according to personal interest or to best meet the demands I perceive. I must instead undertake ordained ‘mandatory’ training on such delights as information governance, and diversity in the workplace. This is boring, irrelevant, and time-consuming, the main purpose appearing to be to protect the monolith for which I work, not to improve the care I give.

When I identify a real opportunity for workplace improvement I have no real power to address it. I pass it up a non-responsive bureaucratic chain to a distant and removed manager, focused on budgets and generalities. My concern is either ignored or cursorily acknowledged and placed at the bottom of a list of priorities with cost cutting, and not service improvement, at the top.” Peter Muchie, BJGP Should General Practice Give Up the Independent Contractor Status 2015.

It is easy to think that we would just turn up for work, see the patients we were asked to and then leave at the appointed hour.  But what we miss is how soul destroying this lack of autonomy will feel, how frustrating the constant interference of a middle manager with a corporate agenda and no insight into the needs of our population will be, and how being at the receiving end of decisions made at an organisational level many layers away will make us want to scream.

The independent contractor model offers freedom for practices to choose how they operate, to flexibly adapt to meet the needs of the patients they serve, and to respond quickly to any new situation that arises and requires action.  This has been a key strength of general practice, one that is not well understood, but one that would be lost if the model was replaced.  It not only enables practices to adapt and thrive in even the most testing circumstances, but also provides partners that Maslowian need for self-determination that a salaried model would take away forever.

The Danger of Integrated Primary Care

General practice is currently being swept along on a tide of change, all based on the premise that what we need is ‘integrated primary care’.  But what is integrated primary care, and is it really what we need?

Despite the status of the Fuller Report not being clear when it was first published over a year ago, it is now being treated as the policy document for general practice.  If you ask anyone working in the system what the plan is for general practice they will say it is to implement the recommendations of the Fuller Report.  But when you read the Fuller Report it is a wordy document that is light on analysis and heavy on pushing ideas, with little clarity on how these new ideas will make things any better.

At the heart of all this lies the idea of integration.  We have moved away from the internal market and now have integrated care systems.  The four stated aims of this new system are to improve outcomes in population health and healthcare; tackle inequalities in outcomes, experience and access; enhance productivity and value for money; and help the NHS support broader social and economic development.  Having reiterated these aims Fuller states,

The ICS CEOs believe that achieving these aims will only be possible if we support and develop a thriving integrated primary care system” p4.

And that is the only rationale that is given.  Primary care needs to be integrated because ICS CEOs believe that is what is needed, and this apparently should be enough because no other justification is given throughout the whole document.  All the NHS CEOs even put their signatures to the report, an act Fuller describes as, “an extraordinary and welcome display of common purpose across health and care” p3.

But could it be that the enthusiasm of the NHS CEOs for this report comes not from a passionate belief in unlocking the power of local communities, but rather because it would increase the span of their direct control to include primary care?  NHS CEOs do not like primary care because the independent contractor status prevents them being able to tell it what to do, so it is not surprising they are all in favour of any move to give them more control over it.  This hardly feels like a sound justification for making such major changes.

A key problem is that nowhere is ‘integrated primary care’ defined.  Without definitions we are in trouble because what I think it means, what you think it means, what Claire Fuller thinks it means, what the 42 NHS CEOs who signed the document think it means, and what the government think it means are all likely to be very different.

Does it mean primary care working effectively in partnership with local health, social care and voluntary sector colleagues in local neighbourhoods?  Does it mean general practice becoming a formal part of the NHS?  Does it mean GP practices becoming part of existing NHS organisations?  We know that this whole range of views already exists.

I am actually a fan of integration, where it means all health and social care providers working more closely together.  It makes sense.  But the notion of “integrated primary care” is actually very dangerous, because it is so nebulous.  It is behind the calls for the nationalisation of general practice, and the end of the independent contractor model.  It is an enabler for centralist CEOs who want to expand their empires.  It is also creating a system blindness to the challenges being faced at an individual practice level.

So what do we do?  In local conversations push for clarity as to what is trying to be achieved and how will we know that we have got there, before getting into the details of actions.  “Implementing Fuller” should not be an end in itself.  If we are implementing an integrated neighbourhood team then what success measures are we using?  What outcomes will it achieve?  Simply ticking the box that we have one does not constitute success.

Challenge the idea of integrated primary care when it is used without clarity of meaning, and push for a local definition that everyone can sign up to.  General practice can support integration, but it mustn’t come at the cost of the service itself.

A Cause for Concern: the Government response to the HSCC Future of General Practice Report

One of the few slithers of hope that we have had in general practice in recent months came from the most unlikely source.  Jeremy Hunt, in his stint as the Chair of the Health and Social Care Committee, commissioned an Inquiry into the future of general practice, and the report the committee published was surprisingly sensible.

The report contained a call for the government to acknowledge the crisis general practice faces, to recognise and prioritise the importance of continuity of care, and to strengthen rather than undermine the partnership model.  You can read the full report here.

The report was published in October last year, and the usual requirement is for the government to respond to such reports within 2 months.  However, in an indication of what was to come, the response took 9 months to arrive, and if I was to use one word to summarise the response it would be “disappointing”.

Maybe it was unrealistic to have any expectation that the report would carry any real influence, but it did seem to have been championed by Jeremy Hunt, who then went on to become Chancellor of the Exchequer, so there were some legitimate grounds for hope.

Unfortunately, you don’t need to get far into the report to realise that it is going to result in no actual change of direction.  Recommendation 1 was that the government acknowledge there is a crisis in general practice.  The response?  The Department “partially accepts” this recommendation, only in so far as some people are facing challenges in accessing an appointment, and the Delivery Plan for Recovering Access to Primary Care has been published to address this.  And that’s it.  If the problem won’t be acknowledged, you can be pretty sure there will be no support to follow.

Essentially the response says that if you take the Fuller Report, the Plan for Recovering Access, the Hewitt Review and the Long Term Workforce Plan, everything that needs to be done for general practice is already being done, and no further action is required.

It explicitly rejects the call to prioritise continuity of care (the main call of the initial report), and responds with, “we note that continuity of care needs to be pursued alongside a parallel focus on access” p13.  The government’s prioritisation of access over continuity isn’t going anywhere soon.

In response to recommendation 26 that the government should reaffirm its commitment to the GP partnership model, it says “The Government confirms there is currently no policy to abolish the partnership model” p21, but then goes on to say, “we wish to support a range of models of primary care provision, including the partnership model”.

In the introduction to the report (p2) it goes a bit further and states, “Realising this broader vision may require significant changes to the way general practice operates and is contracted today. Over the course of the year, we aim to engage with the professions, patients, ICSs, and key stakeholders, on a broad range of themes including contracts, operating models, funding of GP IT and estates, to help inform how to shape general practice for the future.”

There is no doubt, it seems, that further change for general practice is on its way.  The document continually refers back to the Fuller Report as the blueprint for this change.  The Fuller report called for “national partners/DHSC and NHS England” to undertake changes to “the existing legislative, contractual, commissioning, and funding framework, which were out of scope for this stocktake”, and it looks like this process is about to begin.

What this response really highlights is that we are about to have a problem.  Its authors don’t believe a sustainability problem exists in general practice.   They do not value personal lists, continuity of care, or manageable list sizes.   Instead the issues they want to address are those of integration and access. This dissonance as to the issues that need to be tackled between the profession and policy makers is where the root of the conflict to come will lie.

End of Contract ARRS Staff Planning

As the end of the 5 year contract draws closer, and with it the (potential) end of the PCN DES, it is time to ensure your PCN has a plan in place for the ARRS staff.

First of all, what are the questions the plan needs to answer?  Well the key ones are how to maximise the associated recurrent funding, how to ensure the staff are not lost to other providers, and what to do about the ‘additional’ funding that the PCN has contributed.  We should probably also try to work through any future issues that we might be able to foresee.

While NHS England has committed on a number of different occasions to ensuring that the cost of the ARRS staff is met recurrently regardless of what happens to the PCN DES post-March 2024, it has not been clear on how this will happen nor how the amount that will be reimbursed will be calculated.  But if history is anything to go by it seems likely that an arbitrary date will be given with relatively little notice (which could potentially come as early as December this year) and expenditure at that point used as the level that will be continued into the future.

Despite the obvious flaws in such a methodology, using actual committed expenditure seems a much more likely choice for NHS England than committing to the final allocation totals for each PCN.  While this would be a fairer and more equitable choice, it would be more expensive (as there remains an underspend on ARRS budgets) and as such is unlikely.

The recent NHS Long Term Workforce Plan indicated that further investment in additional roles would be at a much slower rate than we have seen over the 5 years of the PCN DES, only introducing half as many of the roles again over the next 13 years.  It therefore seems wise for PCNs to ensure that they are maximising the use of their allocation wherever possible.  Some PCNs have said they are not yet ready for any more roles, but this may be a decision they come to regret in years to come when additional funding for the roles has all but dried up.

Whilst PCNs have been recruiting ARRS roles at a breakneck pace in recent years, other community providers who have not received such extra funding have been looking on enviously.  It seems inevitable to me that once ‘integrated neighbourhood teams’ with a much wider community engagement than PCNs shape up there will be calls for the ARRS staff to take on more of a community centred role and less of a practice based one.

While ARRS staff have an important role to play in improving the health and outcomes of local neighbourhoods, through the PCN DES they were also given an important role in ensuring the sustainability of local practices.  Practices and PCNs would be wise to ensure staff are sufficiently embedded into the practice work alongside the PCN-wide work to make their extraction from it impractical.

An obvious concern is where funding for roles has been topped up with funds outside of the ARRS.  It may be that while the ARRS funding is made recurrent, other funding sources (such as the £1.50 core funding) could potentially cease.  PCNs can work out contingency plans for this scenario, beyond hoping for replacement funding sources.  It may be that ARRS staff are deployed in the delivery of services that are income generating and unlikely to stop (such as enhanced access).  This funding could then be used for any excess beyond the ARRS.

Alternatively it may be that the roles can be redeployed out of existing PCN work and into more focussed practice activities.  Practices may be prepared to fund any additional cost of the roles as is, but this would be more likely if they had more direct control over their time and deployment.

Other factors to bear in mind are the push for NHS terms and conditions for these staff, the move to bring primary and community care workforce planning together, and the expectations those involved in Integrated Neighbourhood Teams (whatever these end up being) may have for ARRS staff outside of GP practices.

The key point from all of this is that working this through now, and coming up with a clear plan to mitigate the risks and maximise the longer term impact of these roles is likely to pay significant dividends beyond March next year.

Are we simply waiting for PCNs to pass?

For those who have been around a long time it is hard not to get cynical, as every couple of years there is a new scheme for general practice that is heralded as the big ‘new thing’ but then fizzles out, and disappears as quickly as it arrived.  Are we not headed the same way with PCNs, and so shouldn’t we be keeping our heads down and simply focussing on the day job?

Bear with me as I take a short trip through recent history.  Back in the early 1990s (voluntary) GP fundholding was introduced, but no sooner had it been embraced by more than half of the practices across the country than it became politically unpopular over concerns of a two-tier service, and it was quickly abolished by the incoming Labour government in 1998.  By this point some practices had become heavily invested in the scheme and its removal represented something of a kick in the teeth.

The Blair government replaced GP fundholding with primary care groups (PCGs).  Here groups of practices were to work together to provide the universal coverage that fundholding had not, with the idea of an indicative budget at each practice level.  However, by 2001 these PCGs were deemed too small and it was announced they were to be replaced by a smaller number of larger more powerful Primary Care Trusts (PCTs), who it was hoped would have more purchasing power.

Of course this meant practices were once again removed from any actual commissioning decisions, and so practice based commissioning was introduced in 2005.  This quickly came beset by implementation challenges, and was ultimately itself replaced (having never really taken off) by Clinical Commissioning Groups (CCGs) when the now infamous Health and Social Care Act was published in 2012.

The death knell for CCGs was sounded in 2016 when Sustainability and Transformation Plans were introduced, as the NHS started on its journey towards integration.  Even though they limped on until the latest Health and Social Care Act had been passed in 2022 they had already effectively been replaced by Integrated Care Boards.

It is not surprising, then, that against such a backdrop of continuous change that many practices are sceptical about Primary Care Networks (PCNs) and their chance of any long or even medium term sustainability.  PCNs were introduced as part of the 5 year GP contract in 2019, immediately after the publication of the NHS Long Term Plan in January of that year, and face an uncertain future as that particular contract draws to an end.

However, when it comes to PCNs there are some important differences.  One is that all the previous incarnations were attempts to place primary care at the centre of the purchasing arm of the internal market model.  PCNs, in contrast, are the first attempt to enable general practice to integrate with the wider system, in this new way of NHS working.

While there were always arguments about the scale required for effective commissioning, there is less debate about the scale needed for integration.  All seem to agree that integration has to start at the local neighbourhood level, and even if you consider Labour’s current shadow health policy they are promoting a ‘neighbourhood health service’.  The pseudo-primary care policy that is the Fuller Report recommends integrated ‘neighbourhood’ teams.

The concerns with PCNs seems to be less about their scale and more about the extent to which they have enabled wider integration.  The debate is also as much about the independent contractor status of general practice (something that never really featured during the purchaser provider era) as it is about PCNs, as this status is regarded as a blocker to integration.

Here is where we get into the real difference of the current situation.  Previously the changes were nothing to do with the core delivery of general practice, but attempts to harness practices as commissioners.  Now the changes are attempts to join up core general practice with the rest of the NHS.  It is not scale that policy makers want to change (the size of PCNs seem about right to them), but the function of general practice behind that scale.

This is important because while for the past 20 or so years a strategy of ‘watch and wait for the latest fad to pass’ has been largely successful, there are warning signs now that such a strategy for individual practices could result in some very unwelcome changes at practice level.

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