Making a Difference

It has been a difficult year.  Coping with Covid-19, and all the challenges that it has brought both personally and professionally has been difficult for everyone.  The first lockdown was hard, but the second lockdown in many ways feels harder, because we understand the scale of the challenge and what will be required to get through it.

This time round some of the fear from the first lockdown has gone, because we know what to expect.  But instead it has been replaced with a tiredness.  Without really having the time or opportunity to recover from the first time round we are having to do it all over again.

For general practice lockdown 1 and lockdown 2 feel significantly different.  When lockdown 1 happened the message was to stop everything to make sure that patients with coronavirus were looked after.  In lockdown 2 the message seems to be that general practice should be open for business as usual, and be absorbing the covid challenges on top of everything else.

Now the ask is for general practice to also take on the covid vaccination programme.

It easy to react from a position of tiredness.  How can we find the energy to take on all the logistical and operational challenges this brings, on top of everything else?  Especially when it feels like we are already running on empty?  I know I personally am guilty of reacting like this.

But the reason I (like many of you) chose healthcare as the industry that I wanted to work in, as opposed to investment banking or commercial law or anything else, was because I wanted to make a difference.  I wanted to not just earn a living, but to do so in way that a made a positive difference to others.

Playing a part in the covid vaccination programme is likely to be my opportunity to make the biggest difference maybe I will ever be able to make.  A vaccine is the only route by which we can re-gain our lives, our economy, our normality.  Without it, as we have seen, the pandemic takes over everything.

So yes it is hard, and it is difficult to summon up the energy and personal resources, but really it is a huge opportunity.  Undoubtedly general practice will rise to the challenge, and play a leading role in taking the country out of the crisis it finds itself in.  I want to be part of it.  I want to know that when it mattered most, I made a difference.

Time for a PCN Stocktake: 10 points to review

A number of PCN Clinical Directors have asked me recently, “What should I be doing now?”.  With so much going on at present, it is no surprise that it is difficult for the leaders of PCNs to remain clear as to exactly where their focus should be.  Just because of the volume of things that are happening, now is a good time for a PCN stocktake.

Investing some time now in a stocktake will help provide a clear sense of direction for the PCN, and help create a renewed sense of focus for the months ahead.

But what should the stocktake cover?  Here are my suggested 10 areas for review:

  1. Member practice engagement. The number one priority for any PCN is its members, because without unity and a sense of collectivism it is very difficult for anything else to be achieved.  It is easy when the agenda gets busy for this to fall to the bottom of the list, but engagement is an ongoing process and it is important PCN leaders do not let it slip.  Within this (of course) is how the PCN has (and plans to) support member practices with covid, flu vaccinations, and (potentially) covid vaccinations.


  1. PCN vision/purpose. It is never too late for a PCN to work on what it is trying to achieve and what it wants to deliver for its members and the population it serves.  Member practice engagement is much easier to maintain when everyone is agreed on the overall direction of travel.  Even if you did this a year or more ago, it is important to keep it under review to maintain alignment across the PCN.


  1. New Roles. PCNs submitted their recruitment plans for this year back in August, so now is a good time to review progress made against that plan.  It is also important to review how well the new roles that have started are working, and what can be done to both help them become more effective and maintain a focus on retention.


  1. PCN DES specification delivery. We are now over a month into the delivery of three new specifications (enhanced health in care homes, early cancer diagnosis, and structured medication reviews).  CCGs seem to vary in the closeness with which they are monitoring PCN performance against these specifications, but better for PCNs to be on the front foot, understand how they are doing, and make any change that are needed themselves.


  1. Social Prescribing Service. It is also a requirement of the PCN DES that each PCN provides a social prescribing service to their patients.  According to the Investment and Impact fund (see below) a PCN needs to offer appointments for up to 0.8% of its PCN population between October and March, so for a 50,000 population PCN that is 400 appointments (15-20 appointments per week, depending on whether or not you have started yet).  Is your PCN’s social prescribing service up and running and how many appointments per week is it offering?


  1. Investment and Impact Fund (IIF). An ‘average’ PCN can earn up to £21,534 in this year’s IIF (for my blog explaining how it works click here).  In the current absence of any national reporting on PCN performance against the IIF, it is worth at least keeping back of the envelope workings out on where you think you are, so that it doesn’t come as any huge surprise when the dashboard finally appears.


  1. Local projects. It is all very well making sure the PCN has done everything that is asked of it in the PCN DES, but to thrive and make a difference locally a PCN needs to undertake at least one project of its own.  Tracking the performance of your own projects is probably more important for the PCN than performance against national directed initiatives.


  1. Local relationships. We are still in the start up period for PCNs, and crucial for future and ongoing success are the relationships a PCN has in place with its local health and social care partners.  Are there individuals in the community trust, acute trust and mental health trust the PCN can contact to sort out issues or take new initiatives forward?  Are relationships in place with the local voluntary sector to enable the nascent PCN social prescribing service to thrive?  Is the PCN working well with the other PCNs in the area?


  1. Preparation for extended access. Looming large on the horizon is the transfer of responsibility from CCGs to PCNs for extended access form April next year.  We are still awaiting guidance on the details of this and what this is going to look like in practice, but a PCN would be wise to at least have started working through what it wants the service to look like, and any major changes (e.g. locations etc) it wants, so that when the guidance does finally land the PCN is in position to move quickly and not lose out on the opportunity simply because the timescales are (inevitably) tight.


  1. Preparation for next year’s PCN DES specifications. We have also had a pretty good preview of at least some of the outstanding specifications that are on the way, in particular anticipatory care and personalised care which were published in draft last year before they were dropped from this year’s requirements.  A PCN would do well to plan how it intends to meet the requirements of the new service specifications, so that it can make sure it has the staff and resources in place to deliver it when the time comes.

The PCN Retention Challenge

After a slow start last year, when PCNs displayed considerable reticence about taking up the additional role reimbursement scheme (ARRS), things have taken off this year.  There is a recruitment frenzy underway, with thousands of new roles being recruited across the country.  But could all this recruitment energy be being expended in vain?

The biggest challenge PCNs face is not recruiting to the roles in the first place (although one colleague described it to me as being like the “wild west” out there, as some PCNs do whatever is necessary to secure candidates – regardless of whether they have already accepted an offer elsewhere).  The biggest challenge will be keeping the ones they do manage to recruit.

For a start, PCNs are not actually organisations.  They are collections of practices, so when an occupational therapist or care coordinator is recruited by the PCN it is not 100% clear exactly who they are working for.  It is this sense of the new staff not belonging that is difficult for PCNs to overcome.

There are already plenty of stories of new staff arriving on their first day who discover they do not have a base (“could you work from home for now…”), a clinical space to operate out of, or any sort of induction.  It is not going to be long before those particular new recruits start looking elsewhere.

Even for those PCNs that have managed to put the basics in place, there is still the challenge for any new starter of working across multiple practices.  Each practice has its own systems, processes and way of doing things.  Will every practice make the new starter feel equally welcome?  Unlikely.  More likely is that very quickly they will start to dread Wednesdays and Thursdays when they have to go to practice X and practice Y.

Introducing new roles into general practice has never been easy.  It is not clear to many GPs and many GP practices exactly what value the new roles can bring to them.  The challenge pre-PCNs of introducing new roles was not a lack of availability of the staff, but a lack of belief amongst practices that they could make a significant difference to the workload.  This has not changed just because PCNs are providing the funding.

What does the dietitian/physician associate/health coach (etc, delete as appropriate) actually do?” and “can’t we just use the money for an extra GP instead?” are not uncommon questions in practice meetings discussing the new starters.  And it is into this environment that PCNs send the new recruits, often without any real warning of what to expect or any support in overcoming known areas of resistance.

Even when all the practices understand the role, know how it is supposed to function, and are fully briefed and prepared for it to begin, it is still challenging for any individual to feel like they belong anywhere, when everyday they are in a different practice working with different people, and always feeling like an outsider.  When hostility is palpable in half of those practices, the experience goes from feeling like an outsider to more like an unwanted intruder.

Clearly the new roles will work better when they are in, and feel part of, a team.  But what should the team be?  Should they have a ‘host’ practice, and become part of that team? Or should they be part of the team of all the new roles working across the PCN?  Or should it be by professional group – so all the pharmacists form one team, maybe across multiple PCNs?  Or should it be a PCN project team working on something across the PCN, which includes members of existing practice staff as well as the new roles?  Or something else?

I am not sure it matters what the team is, but for the (lack of) ownership issue to be overcome I am sure it is vital that the new roles are part of a team, with a leader, clear objectives, and identified support.

I know some places have done this, and where they have many already have a waiting list of applicants disillusioned with their new life elsewhere who are keen to join.  Recruitment may have been very challenging over the last few months, but it will all have been for nothing if that effort is not at least matched with an equal effort to look after these new staff.  High turnover rates in these new roles is extremely likely in the coming months, and the winners will not be those that pay the most but those that provide the best support.

Do PCN finances stack up?

I understand the primary aim of PCNs is not to be a source of income for practices, but it is important they don’t become a drain on already under pressure practice finances.  So do PCN finances stack up?

Just as a reminder, the aim of PCNs (according to the BMA) is to focus services around local communities, help rebuild and reconnect the primary healthcare team across the area, alleviate workload, be practice-led, and allow GPs and primary care practitioners to deliver a new model of care for their patients and communities.  It is interesting there is no mention of money, despite the financial challenge in general practice PCNs are supposed to be part of the solution to.

The headline investment figure into PCNs is the Additional Role Reimbursement Scheme (ARRS), which brings with it total investment of £1,412M by 2023/24, equating to an average reimbursement pot of £1.13M per PCN.  Member practices receive a £1.76 participation payment.  PCNs directly receive £1.50 core funding (which I discussed last week), 2 to 3 sessions reimbursement for a Clinical Director, and the Investment and Impact Fund – the proceeds of which PCNs have to commit to reinvesting in additional workforce or primary medical services.  There are also extended hours payments and care home “premium” payments, but these are funds for specific pieces of additional work.

The eye catching figure is of course the investment via the ARRS.  But what is increasingly emerging are a set of hidden (and not so hidden!) costs for PCNs and their practices associated with these roles.

Many areas have not been able to recruit the roles within the salary reimbursement available, and each role where this has been the case becomes a cost pressure on the PCN.  These cost pressures will accumulate as more roles are added, and as staff expect pay rises beyond the reimbursable amounts available.

It is also unlikely the on costs will meet the training, supervision and professional development costs of the roles, along with equipment and property costs – apparently NHS Property Services has recently stated that where its property is used to house PCN services this will incur additional property costs for those practices.

When PCNs were first being set up there was quite a bit of talk about the risk of incurring VAT, but that died down relatively quickly.  However, as PCN turnover starts to exceed the VAT allowance of £85,000, which it increasingly will do as the number of roles recruited to increases, then the spectre of this charge will quickly re-emerge.  There is no obvious source of funding to meet any such VAT charge, other than directly from member practices.

The other issue for PCNs to consider is whether they should be creating a financial buffer, to mitigate the potential risk of any employment costs that may arise out of the new PCN staff group.  Often companies will try and ensure they have at least three months of salaries as a financial buffer, which by 23/24 would be £250-300K for an average PCN.  That money will need to come from somewhere.

What approach, then, should PCNs take to PCN finances?  It seems to me that PCNs have one of two choices.

They could choose to think about PCN finances in terms of the net impact on member practice finances.  This would mean practices actively monitor the total positive impact on practice profitability of the PCN.  They would take the £1.76, the impact of the new roles in reducing staff costs, and any increase in income from PCN contracts, and subtract any direct costs to the practice of the PCN, such as financial contributions, property charges and staff time, and ensure that it remains net positive.

The key to making this approach work would be ensuring each practice receives a direct positive impact from the additional roles that are brought in, rather than treating them as PCN-staff that are not really anything to do with the work of the practice.

The other option would be for PCNs to operate financially like a business.  The principle here would have to be that the total income of the PCN should match the total costs.  Outside of the DES contract itself there are soft funding pots available, both through the national PCN development funds and local initiatives.  The Investment and Impact Fund was initially presented as an opportunity for PCNs to earn money by reducing secondary care expenditure, but that was lost as it was watered down into what we have now.  The big potential income generating opportunity on the horizon is the shift of extended access funding to PCNs from next year.  It remains to be seen whether this too will still exist once the final guidance has been agreed.

My worry is that many PCNs at this point in time are not taking either of these approaches.  PCN finances can stack up, but to do so will require active financial management.  The big risk is that without this in place PCNs could end up having a significant negative impact on member practice finances.

The £1.50 Challenge

Each PCN receives “core funding” of £1.50 per patient.  The Network DES states, “A PCN is entitled to a payment of Core PCN Funding for use by the PCN as it sees fit” (9.5.1).  This freedom has created a level of ambiguity around the use of this funding that is hindering rather than helping most PCNs.

If we start at the beginning, there is no way that £1.50 per patient (c£75k for the average PCN) is sufficient to cover the running costs of a PCN.  A PCN will soon be employing upwards of 20 staff, and be managing a budget well in excess of a £million.  It is not possible for the administrative overhead to be £75k and expect payments to staff and practices to be made accurately and on time, for staffing issues to be dealt with appropriately, and for the huge system expectations of PCNs to be met.

A helpful piece of context might be the running costs of CCGs.  When they were established they were allocated £25 per patient (which was still a cut on the running costs of their predecessor PCTs).  Admittedly PCNs are not statutory organisations like CCGs, but the expectations are still high, and having only 6% of the running costs given to CCGs highlights the challenge PCNs are facing.

PCNs may have been able to get by so far, as the actual demands have been limited to sorting out extended hours and some early recruitment.  But now there are new staff in post, 3 service specifications to deliver, and with the prospect of sorting out extended access on the horizon things are soon going to feel very stretched.

The challenge many PCN Clinical Directors (CDs) are facing is their member practices do not want the £1.50 to be spent, and resist proposed uses of the fund.  Because the expectations were relatively light in year one some PCNs were able to return some (or even all) of the £1.50 to member practices.  This in turn has set an expectation that practices will receive some such funding directly from the PCN each year.

So when a new PCN manager is under pressure it can often turn into questions to the CD from practices about what value are we really getting from this role anyway?  And before you know it, the PCN has decided they do not need a PCN manager after all.

Other PCNs have turned to the £1.50 to make up for the shortfall in the ARRS funding for the new roles.  So where the roles have come with additional costs (salary shortfalls, training supplements, venue/location costs etc) the £1.50 has been used to meet the deficit.

The problem of course is that this will only work for the first couple of roles.  If you are cutting £75k across more than 20 roles it is not going to solve the overall funding shortfall problem that the ARRS scheme presents.  At the same time, it is eating into an already underfunded running cost allocation.

I have written previously on how essential the PCN manager role is.  There is a rumour that PCN managers may be included in the next list of roles that can be funded from the ARRS.  But whether it is or isn’t, no individual can be an expert change manager, project manager, finance manager and HR manager.  PCNs need a team of support to be successful.

The £1.50 challenge for PCNs, and particularly for PCN CDs, is how to withstand pressure from member practices not to spend it or to spend it on topping up additional roles, and instead to use every penny to put in place the best possible support infrastructure for the PCN.  Because without it, the PCN is going to struggle as it moves forward.

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