Tackling the End of PCN DES Uncertainty

Many PCNs are finding the proximity to the end of March when the PCN DES comes to end a real challenge.  Practices are disengaging from the PCN because of the uncertainty as to what is coming next, and it is difficult for PCN leaders to coral the practices into any form of collective action.  Given this situation is a period of limbo inevitable, or can a more productive use of the time remaining be found?

Well the reality is that we are not surrounded only by uncertainty.  There are some things that we do know.  We know that next year there will be a one year “stepping stone” contract, in which we will see a continuation of PCNs more or less as they are, along with some “pointers” as to what may be to come.  There will be an election next year, and so any major changes will not happen until after a new government is in place.

We know that the funding for the ARRS roles will continue.  While we do not know exactly the form that this will take, given that PCNs are to continue then most likely is that the ARRS funding will also continue more or less as is.

We know that there is not going to be any backtracking on the funding for general practice that comes through PCNs.  At present over 25% of funding comes via PCNs, and because the system’s number one goal is to “integrate” general practice with the rest of the system then it is not going to revert from 1250 units (PCNs) to 7000 units (practices).  It simply is not going to happen. We also know financial pressure on individual practices will continue, and there will not suddenly be more GPs.

We know that what is coming next is going to be some version of PCNs working more closely with the other health and social care providers in the local neighbourhoods.  The original PCN DES back in 2019 said that the DES would be “amended from 20/21 to include collaboration with non-GP providers as a requirement”.  While this never happened because of Covid, the Fuller report (now de facto national primary care policy) has outlined exactly this in its description of Integrated Neighbourhood Teams, and it has become clear since that PCNs will operate as the general practice part of these teams rather than become them.

We are also aware of a couple of reasonably significant risks for general practice.  There is pressure in the system for more general practice resource to be controlled locally rather than nationally.  It is also likely that systems will seek to access PCN resources for the sole purpose of neighbourhood working, disregarding their additional function of supporting core general practice.  Both represent significant risks if general practice is not able to influence effectively in local systems.

Given we know all these things there are two actions that are sensible.  The first is for PCNs to create their own plan to manage the end of the PCN DES.  This would include getting the relationships between the practices to a place where the opportunity of the PCN can best be maximised by all (see last week’s blog), and freeing up some of the PCN leadership time to both start the process of building relationships with local providers and to engage in work to strengthen the voice of general practice within the local system.

The second is to refresh the vision for the PCN (if there is one).  I have written previously about this, but essentially unless the practices in the PCN have their own vision for what they want the PCN to achieve then the system is highly likely to impose is its own priorities for the PCN.  With the system changes around integrated care and integrated neighbourhood teams this is more of a risk than ever, so it is critical that practices are clear on the direction they want to take together so that they can shape any future changes into this direction, rather than allowing these changes to determine where they are going.

Working together to create a plan that focusses on those things that you can control and on mitigating the biggest risks is extremely empowering.  It is a much better way of dealing with the uncertainty than taking no action and waiting for a new direction to be imposed, and is one that is much more likely to achieve a better result for both the PCN and its practices.

PCNs and Practices

We have a problem in general practice.  The system wants to work with units of general practice that are PCN-sized.  Practices, however, are (in the main) not PCN-sized and have no intention of becoming so.  The system is carrying on regardless.  What does this mean for practices?

Dr Steve Taylor recently posted on X that while the global sum for GP practices stands at £104 per person, PCN funding is now at £38 per person.  So over a quarter of all the funding coming into general practice now comes via PCNs.  The system’s desire to work through PCN-sized units of general practice means that the amount of funding coming through PCNs is going to continue to rise.

If we know that this is how things will develop in the future (regardless of the rights and wrongs of the policy), what is the most sensible way for practices to respond?

An increasingly common response is for practices to focus on ensuring that the practice receives its share of the funding that comes into the PCN.  The practice has no real interest in the collective of practices that is the PCN or its joint work, but does everything it can to ensure as much resource as possible is directed to individual practice level.

For PCN Clinical Directors this can be hugely frustrating.  They constantly feel like they are having to battle to ensure the PCN is able to fulfil its requirements alongside meeting these requests from practices.   The PCN and the practices end up feeling like they are disconnected and are frequently at odds with each other.

This scenario has lost sight of one really important fact.  The only people who are supporting general practice right now is general practice itself.

There is no other support available.  The system has become distant, remote, and preoccupied with access and system working.  There is the CQC with its new practice inspection framework, alongside a system that has introduced legislative changes to force practices to work differently.  Noone else is on the side of practices.

The most accessible form of support is actually from the other practices in the PCN, alongside the PCN itself (and local federation if there is one).  The opportunity exists to learn from and support each other.

The problem with the “give everything to the practices” approach to PCNs is that it misses this opportunity for support.  Instead, it deepens the historic sense of divide between practices and entrenches the barriers around each practice, despite the challenges that nearly all practices are facing.

To maximise the value of the total of the funds coming into general practice, both now and in the future, practices in the PCN should consider what is best done individually at the level of the practice, and what is best done collectively at PCN level.  Regardless of what some might say, there is value in some things been done once across the group of practices in a PCN.  Equally some things need to be done at individual practice level.  Even then, there is value in each practice taking the time to learn from the other practices on how actions at a practice level are carried out, and in supporting each other to ensure the best systems and processes are in place at each practice.

The PCN has a key role in enabling this.  The current focus on access is a perfect example.  The role of the PCN is not to put together a PCN plan that the system will sign off on, and leave the practices to work on their own to meet the new access requirements.  Instead, it is to ensure that the best balance of PCN provision and practice provision is agreed and put in place, and that practices are given the opportunity to share and learn from each other so that they are each equipped as best they can be to meet the new requirements.  Practices can and should be supporting each other because they are in this together.

PCNs can either be a barrier to practices receiving their share of the funding, or they can be an enabler of efficiency, innovation and support.  Practices are not in competition with each other, and treating PCNs as a practice competition for resources will ultimately mean that all the practices in the PCN suffer as a result.  For practices to survive in this new world of integrated care systems, they must work together and support each other wherever and whenever they can, and it is the PCN that creates the opportunity for this to happen.

Beware Distance from Practices

At-scale working in general practice has a chequered past.  While there are obvious economy of scale benefits, the reality is that many attempts to function at-scale have floundered.  What can we learn from the past, and what might the implications be for PCNs and their development?

Although PCNs are only approaching their 5th birthday, at-scale working in general practice has been around for much longer.  Federations, super-practices and even CCGs have all attempted to bring practices together in different ways.

The key lesson from all of these is that a dissonance, or even a perceived dissonance, between the at-scale organisation and the practice unit causes challenges and impacts the ability to work collectively.  Where there is a perfect unity of the at-scale entity and the individual practice units then much can be achieved, but where cracks between the two appear then the ability to deliver the benefits of working at-scale quickly dissipate.

We see this with federations.  The most successful federations have a strong relationship between the practices and the federation, and a high level of trust between the practice partners and the federation directors.  Conversely, federations struggle where the practices have concerns that the federation may be in competition with its practices (for example over the delivery of enhanced services or a local APMS practice), may be working for its own ends rather than those of the member practices, or may be taking on a performance management rather than support function for its members.

Super-practices may be one organisation but in some tensions can exist between the individual practice units and the ‘centre’.  While the ability to make collective decisions is certainly easier as a single entity, if trust between the practice units and those running the wider entity break down cohesiveness is still difficult to achieve.

CCGs, meanwhile, really had no chance.  Right from the outset the CCG authorisation process made clear that CCGs had to prioritise the wider health economy over general practice, and put in place systems to ensure that CCGs did not make any decisions that might favour general practice.  It was no surprise, then, that practices quickly worked out that the CCG was something separate from them and paid little attention to requests for collective action.

PCNs have two advantages that these previous attempts at at-scale working did not.  First is that they are an extension of the GP contract.  They are formed out of a shared enhanced service contract (the PCN DES) and as such are firmly rooted in core general practice.  They are not a separate entity that exists in addition to the practices , but rather are an extension of the practices themselves.  This means the sense that PCNs are somehow in competition with the practices does not exist, as the separation that particularly federations intrinsically begin with is not present for PCNs.

This brings a word of warning for PCNs that choose to incorporate.  While incorporation brings a protection for individual practices from PCN liabilities, it also creates a new distance between the PCN as an entity and the practices themselves.  Once incorporated the PCN is very clearly something different from its practices, which could in time lead to more of a separation between the two.

The second advantage that PCNs have is the limit to their size.  It is much easier to maintain trust, aligned values and strong communication across a small number of practices and GP partners over (say) a 50,000 population than it is for those at-scale entities serving 100,000+ populations.  The more people involved and the wider the geography served the harder it is to maintain the alignment needed for practices to move together as one.

The most successful PCNs are groups of practices working together to be able to better serve their population both collectively and individually.   They trust each other and identify where working at a PCN or a practice scale is better for any given situation.  Other PCNs either have a divide between the work of the PCN and the work of the practices and a conflict between the two, e.g. in the deployment of ARRS roles, or have no sense of the collective and instead have a constant pull for any PCN resources to the individual practice level.

For many PCNs getting this right remains a work in progress.  The danger is this journey may be derailed by changing what PCNs are too quickly.  If the system becomes impatient for Integrated Neighbourhood Teams (INTs) that pull the focus of PCNs into whole system working and away from their practices too quickly, they risk ending up the same way as many previous attempts of at-scale working, i.e. disconnected from practices and not able to take the service with them.

A Glimpse Into Next Year’s Contract?

The NHS Confederation has published a new document entitled, “Supporting General Practice At Scale: Fit for 2024/25 and beyond”.  In it they have, “identified a set of tangible recommendations for the upcoming GP and primary care network (PCN) contracts for 2024/25”.  What are they saying, and what might this mean for next year’s contract?

The first question is why the NHS Confederation are producing such a document at all?  It seems the answer to this lies somewhere in the midst of the fact that discussions between NHS England and the BMA/GPC have not progressed over the last two years (hence two years of imposed contracts) and so NHS England has started to turn elsewhere to have conversations about the future.

Whether the NHS Confederation, an NHS membership organisation that within primary care has PCNs and GP Federations as its members, has legitimacy to talk on behalf of core general practice is questionable, but that hasn’t prevented the publication of this report, and someone, somewhere is funding this work.  The NHS Confederation Primary Care Network is clear that its aim is to “drive the future direction of primary care”, and the report explicitly states that NHS England and DH participated in its production (p9).

The report talks about contracts for practices and PCNs, as if the two are separate.  At present the PCN DES is a part of the national GMS contract, but without explicitly calling for the two to be separated the report does treat them separately.   Are PCNs a group of practices operating together and so an extension of practices, or are they separate entities in their own right?  The gap between at-scale GP organisations and their member practices is what ultimately has caused most of them to fail, and such a separation will likely have disastrous consequences for both practices and PCNs.

The report reinforces the now prevailing belief that next year (2024/25) will be a “stepping stone” contract (p8), ie one with limited change but which will start to point towards a future direction.  It talks about having “Pathfinder” PCNs in 2024/25 to model new ways of working for PCNs that can “demonstrate a level of maturity and innovation” (p19).

The document lays out the “asks” that it says will underpin the future direction for general practice.  Some of these are very specific, including to explore limited liability partnerships holding PMS and GMS contracts, and the contract to rise with a new pay uplift clause.  It also has this as a short term ask, “Explore proven delivery models that will improve practice resilience and sustainability, enabling a mixed economy that continues to support access to services for patients” (p13).  It is not clear what this actually means, but it could be read as a pointer to NHS organisations running practices.

There is also an ask that, “National primary care contracts should be streamlined, retaining a core national focus on areas of high impact” (p19).  Again, it is not clear what this means.  It could mean less prescription on what is required, or it could mean shifting funding out of the national contract and into local contracts, and the problem is people will hear what they want it to mean.

The report contains many of these “asks”.  The report is worth reading to see what they all are.  Many are sensible, some less so, and some have an obvious bias towards at-scale general practice.  The biggest problem, greater than the lack of clarity as to what some of the asks actually mean, is understanding who is asking whom for these things.  Implicit is that primary care is asking NHSE/DH, but there is some considerable distance between the asks in this report and the ‘Call to Action’ document produced by the BMA earlier this year.  I suspect a substantial number of these asks would struggle to gain support if they were presented at the national LMC conference.

But NHSE and the DH want to move forward with their plans for general practice, and if the BMA will not engage with them in a conversation about these plans it is hardly surprising that they are turning to those that will.  This in turn means that despite the mandate issues around this document it potentially could have very significant implications for next year’s contract, and this is probably our first glimpse of the types of things we can expect to see coming.

Look After Your Physician Associates

It is a difficult time for physician associates right now.  The current barrage of criticism from across the media continues to scale up, and being in the midst of it must be extremely disconcerting and isolating.

The current storm appeared to start back in July, when Pulse magazine reported how a practice in North London had decided to stop employing physician associates following an incident in which a patient died after seeing their physician associate.  This incident was then picked up by Labour MP Barbara Keeley, who raised the issue in parliament.

Since then the media criticism of physician associates has been unrelenting (e.g. this, published on Saturday, where a reporter has trawled though the Physician Associate podcast episodes to create a negative story, or this in the ever-unhelpful Daily Mail).

The medical profession has concerns about physician associates.  This BMJ article explains them pretty well, that patients can be confused as to who they have seen, and the amount of supervision required to ensure safe care.  The safety concerns are particularly great in general practice, where the partners are ultimately liable for the decisions made by all of those in their clinical team.  The problem is that the current (negative) media coverage has prompted these concerns to be liberally aired, which in turn has served to fuel the fires.

Imagine you are a physician associate working in general practice in the midst of all of this.  It cannot be easy.  I spoke to physician associate James Catton recently on the podcast about what it is like, and he said, “I have never seen the backlash or the level of issues being brought up across social media that are anti-PA.  It’s been pretty brutal these last few months to see… It’s not a great time to be a PA.  A lot of PAs feel there is sometimes a target on our back at the moment”.

You probably would not know it, but this week (w/c 6/10) is physician associate week.  This was the fanfare surrounding the week last year on the Faculty of Physician Associate’s website.  This year there is nothing.  Unsurprisingly physician associates want to keep a low profile.  So just at the time when normally there would be some additional national support there isn’t any.  Just the constant media criticism.

Maybe you have your own reservations about physician associates.  That is understandable.  It is a relatively new profession, that still does not have regulation in place, and that is still trying to find its place in the wider health system.

But physician associates are not a luxury.  There are not enough GPs to manage the (growing) workload, and there never will be enough.  In 2016 the government pledged 5,000 additional GPs, and in 2019 this target was upped to 6,000.  Despite a huge investment in training numbers the amount of GPs remains static, as the number leaving continues to match the numbers entering the profession.  In an ideal world there would be enough GPs, but given that is not a realistic possibility different roles are now a necessity.  For its own sake, general practice needs to make these new roles work.

And, ideologies aside, there are people in these roles now – an estimated 2,000 currently working across general practice.  The concerns about their role are largely outside of their control.  They have taken on a role in good faith, and now feel like they are being pilloried for it.  They feel under fire.  They need help, support and encouragement.

Maybe we should approach physician associate week differently this year.  Maybe it should be about taking time out to provide some support to those physician associates that are working with us, to say that we recognise the personal challenge the current situation must present, and to let them know their efforts are appreciated.  A little support now could go a long way in future.

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