5 Things to Watch Out For in 2022

What is on the horizon for general practice in 2022?  Here are 5 things to watch out for in the year ahead.

February: Contract Negotiations.  We are three years in to the 5 year deal agreed in 2019, so you would think that contract negotiations this year would be relatively straightforward.  However, once you throw in Covid, the government’s concern with GP access, a new GPC leadership team, and the vote in support of industrial action made by the profession at the end of last year, the negotiations this year could well be a spikier than normal affair.  Despite the profession’s reaction there has been no softening of the national stance on GP access, and so it will be very interesting indeed to see what comes out of this particular set of negotiations.

March: PCN Review Report.  In November last year a review of PCNs was announced, and how “they will be working with partners across newly formed integrated care systems”.  Potential concerns were highlighted at the time, namely that it implied a need for more national control over PCNs, that it could signal a shift of ownership of PCNs away from practices, and that it may very well further distance PCNs from the pressing issue of general practice sustainability.  This report is due in March, most likely coinciding with whatever comes out of the contract negotiations, and there is a good chance it will have big implications for general practice.

June: 3 years of PCNs.  It may only feel like yesterday but in June it will be three years since PCNs were first established.  PCNs now, with their large team of additional role staff and increasing set of delivery responsibilities, are significantly different from what they were back in 2019.  However, three years may also mark the end of the tenure of many of the initial PCN clinical directors.  While we have experienced some turnover of CDs already, this year could well see a much a greater turnover with many coming to the end of the term they initially agreed, and taking on the role may prove a tough challenge for those coming new into the role this year.  How this affects PCNs as a whole is something only time will tell, but unless more support is put in place it is unlikely to be positive.

July: Integrated Care Systems go live.  It feels like we have been living in the shadow of integrated care systems for some time now, but (according to the new planning guidance) they will finally go live in July this year.  This means CCGs will formally be abolished, and general practice will be left to fend for itself amongst the other providers as we all ‘work together’ to agree how care is organised and how resources are divided.  The extent to which general practice can influence and impact these new systems may well be very important in determining the level of local investment and support in the service going forward.

October: Shift of Extended Access to PCNs. Well, maybe.  This shift was supposed to happen in April last year, and then in April this year, and now in October this year, and the continual delays do raise the question as to whether this shift will ever really happen.  But if it does it may well spell the end of financial sustainability for the significant number of GP federations that rely on this funding, and this in turn could well create difficulties for both local practices and PCNs.  It is an issue that when the guidance (finally) comes out will need some working through to ensure we don’t end up with more problems than we have now.

What this Year’s Planning Guidance Means for General Practice

Each year the NHS publishes planning guidance.  This year is no different, and on Christmas Eve (happy Christmas everybody…) true to form the NHS published “2022/23 Priorities and Operational Planning Guidance”.   It outlines for the NHS what needs to be achieved in the year ahead.

While it is not a document specifically aimed at general practice (rather it is aimed at the NHS as a whole), it provides an interesting perspective on how general practice is viewed within the system, what the priorities for general practice are likely to be, and gives some indication as to what will feature in next year’s GP contract.

The document sets 10 priorities for the NHS.  General Practice explicitly features in one of them, namely to, “Improve timely access to primary care – maximising the impact of the investment and Primary Care Networks (PCNs) to expand capacity, increase the number of appointments available and drive integrated working at neighbourhood and place level” (p6).

So first off, in case anyone thought there might be some national backing off from the October guidance that generated such a backlash (including a mandate for national strike action for the GPC), there is a clear reinforcement of the need for the paper to be implemented (“In line with the principles outlined in the October 2021 plan, systems are asked to support the continued delivery of good quality access to general practice through increasing and optimising capacity, addressing variation and spreading good practice” p25).

More interesting is the newer theme that pervades the text around integration.  Integrated Care Systems go live next year, although this document confirms that this will now happen on July 1st not April 1st to allow time for the bill to pass through parliament.  Systems are exhorted to, “maximise the impact of their investment in primary medical care and PCNs with the aim of driving and supporting integrated working at neighbourhood and place level.  Systems are asked to look for opportunities to support integration between community services and PCNs” p24.  The review of PCNs will be reporting in March, and I wouldn’t be surprised if it marks a shift of PCNs away from ownership solely by practices.

Systems will also be judged by the extent to which their PCNs have made use of their ARRS allocation, and are also asked to support employment models across organisations, “Systems are expected to support their PCNs to have in place their share of the 20,500 FTE PCN roles by the end of 22/23 and to work to implement shared employment models” (p24).  It is interesting that underneath the opportunity for PCNs to use the ARRS funds there is a top down pressure on local systems for all the money to be spent.  Indeed, the rationale used is not to support general practice, but “to support the creation of multidisciplinary teams” (p9).

There is a further notable nuance that PCNs (not practices) are treated as the unit of general practice in the guidance.  It claims that there will be, “ a suite of national GP recruitment and retention initiatives to enable systems to support their PCNs (not practices) to expand their GP workforce and make full use of the digital locum pool” (p9).  We also won’t hold our breath in anticipation of all the same additional GPs we have been promised for the last 5 years…

There are two other major items of note for general practice in the guidance.  The first is the big push in the guidance on the roll out of virtual wards.  The ambition set is that by the end of 2023 there will be 40-50 virtual wards per 100,000 population.  These are to be based on a partnership between secondary, community, primary and mental health services, and they “should only be used for patients who would otherwise be admitted to an NHS acute hospital bed or facilitate early discharge” p21.  £200M in 22/23 and £250M in 23/24 is being made available to develop these wards, although given the numbers of wards expected how they will work is a mystery, as my back of the envelope calculation gives each ward less than £10,000 to operate.

The other item of note is a promised new IIF indicator for PCNs to incentivise contributions to a minimum of 2 million additional pharmacy consultation appointments in 2022/23.  According to the guidance (p25) this will move “more than 15 million appointments out of general practice”!

Overall, the main takeaway is the pressure that will come around ‘integration’ – PCNs and PCN staff to work across organisations, multidisciplinary teams, multi-organisational virtual wards, joint working with pharmacies, and (of course) new integrated care systems in charge of everything.  What could possibly go wrong?

2021: The Most Challenging Year Ever?

2021 has been quite a year.  What can we takeaway from everything that has happened, and where are we now as move towards 2022?

The year started with the vaccination programme (in a way hugely reminiscent of everything that is happening right now).  When things were critical, and a fast response was needed, it was general practice that the NHS (and the government) turned to.

For the first months of this year, the vaccination programme was exhausting.  There were real concerns that the programme would prove to be too much for general practice.  One GP predicted at the time, “Prediction for GP in England. It will deliver on the vaccination demands. Delivered for most partners at a loss because of the awful NHSE and GPC ES. Once the pandemic is over many GP partners, PCN CDs and practice managers will resign, broken.” (here).

While we didn’t end up with mass resignations, there was certainly a withdrawal from the programme by many because the constant demands were proving simply too much.  And when the delivery demands of general practice as a whole were increased in April, despite the ongoing demands of the vaccination programme, it did raise the question of who is looking after general practice?

No one, it transpired.  As complaints from the worried well emerged via sections of the press, rather than defend the over and above contribution already made by the service NHS England responded with a letter in May mandating practices to offer face to face appointments.  Understandably, this did not go down well.

Despite some huffing and puffing, at the time no real response was made by the service, much to the consternation of many.  But a few months later NHS England’s publication on improving access and “support” for general practice (essentially how they were going to performance manage practices into offering more face to face appointments) proved to be the straw that broke the camel’s back.

By this point the demand on the service had become so great that the model of access to general practice now required a virtual or telephone triage to protect the face to face appointments for those who really needed them.  Instead of supporting the use of this model, and helping to explain it to the wider population, ministers and NHS England spent time on national TV promising anyone who wanted a face to face appointment with their GP that they could have one.  Nothing could have been either less helpful or more incendiary.

As a result the BMA balloted on industrial action, and supported by the service it now has a mandate to take into next year.

The other big development in 2021 was the shift of the whole systems towards integrated care, as a replacement for the historic commissioner provider split.  The White Paper was published in February, and while it is still making its way through parliament the NHS has been moving at pace to be ready for its approval and it becoming legislation.

It has been a challenge trying to work out what the new system means for general practice.  Design guidance followed for the service in June, and we started to understand the importance of local place based arrangements for general practice, as well as the role of PCNs in representing practices in these models.

The big concern is that there will be a loss of influence for general practice.  While CCGs are (supposed to be) GP led, there is no such requirement of integrated care systems.  Indeed the formal role of GPs in the new arrangements is relatively limited, and leadership of the new system by general practice feels unlikely.  But, as ever, general practice has worked its way through the issues, and areas have worked out that by PCNs, federations and LMCs coming together general practice can have the strongest voice in the new system.  The overall strategy needed is one of pushing decision making to the most local level possible, working together to create a single local voice for general practice, and then using this voice to influence decision making locally.

Here we are at the end of the year, with the service feeling very much on the precipice.  Integrated care systems are due to go live during 2022 (dependent on when the legislation finally gets approved), industrial action looms (one assumes depending on the outcomes of contract negotiations early in the new year), and covid is fighting back to add yet more pressure on to the service.

We have now come full circle with a new call to arms for general practice to once again lead the vaccination charge for the country.  Let’s hope next year there is both more appreciation for the critical role general practice plays, and more support for the service to recover from what has undoubtedly been one of its most challenging years ever.

GP Partner Training – the Learning So Far

Earlier this year myself and a group of colleagues decided that we should put in place the training for new GP partners that we had been talking about for such a long time.  The course finally started in September of this year, and we have already learnt some interesting lessons along the way.

I teamed up with Tara Humphrey, PCN management expert, Director of THC Consulting and presenter of the Business of Healthcare podcast; Robert McCartney, general practice governance expert and Director of McCartney Healthcare Associates; Dr Naj Seedat, GP, trainer, partner in a large North East London practice and LMC Chair; and Dr Farzana Hussain, GP, GP appraiser, mentor, trainer and lecturer.  Together we formed a really strong team, designed to be able to meet all the development needs of new and aspiring GP partners.

We designed the course into 20 sessions, broken down across three broad areas: understanding the business (i.e. what goes on within the practice); understanding the environment (i.e. what is happening around the practice that affects it); and understanding the risks (i.e. how do you build a strategic plan for the future).  Naturally the weighting of the first area is greater than the other two, as there is so much within the business of a practice for any new partner to get their head around!

We wanted the course to not be too demanding on GP time, which is why we went for the model of an hour a fortnight over a period of 9 months.  This has worked to the extent that it has made the course manageable in terms of time for participants.  The challenge, however, has been how to cover such huge topics as managing people or understanding premises in just an hour.

We have been working hard to do this well, but for some topics we just had to extend the sessions.  For example, when accountant James Gransby ran the session on understanding the practice finances we had to make the session an hour and a half.  Even then it was hard to cover everything for such a complex topic!

The other challenge we have experienced is how to make the sessions interactive when there is so much content to work through.  In an hour the scope for really interactive sessions is limited, but at the same time the more interactive the sessions are the more valuable they can end up being for participants.

Another lesson we have learned is that one of the biggest challenges new partners experience is taking on the role as a business owner and what this means in terms of how they lead and manage staff.  This is a really critical area for GP partners, as their leadership style really affects the culture of the whole practice.

As a result of all this we have made some changes to the programme, for the next cohort of new or aspirant GP partners who will be joining.  In the new format content will be delivered over six monthly half day sessions.  This will allow us to create longer, more interactive sessions where we can tailor the content to the specific needs of those on the programme.

We have also included core strengths training as standard, as it really helps new partners understand and develop their leadership style, and given over a whole half day session to leading and managing people.

We always knew developing this training would be a journey, and that we would be learning as we went along.  We are delighted with how the programme is going so far, and excited to make the changes to make it even better going forward.

The programme for our next cohort commences on the 1st February 2022.  We still have some places remaining, so if you or someone in your practice is interested you can find all the details here.  Alternatively get in touch and I am happy to talk through individually what we are doing so that you can work out whether it is right for you – I’m ben@ockham.healthcare.

50 to 1

I am spending some time working with a number of areas thinking through how to create and develop a strong, unified voice for general practice, that can be effective and influential within the new integrated care landscape.  It is a challenge that is harder than it sounds.

The problem comes because “general practice” in any given area generally consists of about 50 different, independent, autonomous organisations.  There are the 40 or so individual practices, 5 to 10 PCNs, maybe a federation, and the LMC.  How do you get 50 organisations to speak and act with one voice?

There is a framework that is quite helpful to consider in this context, called the Cynefin Framework.  Essentially it breaks problems down into different categories.  For our purposes what is helpful to understand is that there is a difference between simple, complicated and complex problems.

Simple is a problem that has a relatively straightforward solution, such as how do I lower my car window.  There is a specific, straightforward answer (press the right button).

Complicated is a problem that does have at least one solution, but which can be difficult to deliver.  An example that is commonly used is sending a rocket to the moon.  It is not a simple thing to do, and may well require multiple teams and specialised expertise.  But by really effective project planning, and using the experience of those who have done it before, it is possible to create a path to making it happen.

Complex problems are ones that are impervious to a reductionist approach that strips the problem (however complicated) down to its core components to work out the solution.  The example commonly used is raising a child.  There is no handbook because each child is unique.

For a complicated problem you can use a project planning Lewinian style approach to solving it.  But for a complex problem the approach needed is an emergent one, using trial and review (like PDSA cycles for you NHS improvement fans, or probe, sense and respond which Snowden, who introduced the Cynefin framework, uses).

This distinction is useful because in healthcare we commonly describe complex problems as complicated ones and hence employ solutions that are wedded to rational planning approaches.  We look for business cases with defined outcomes as a default mechanism for moving forward, when this approach can only work for something that is simple or complicated, not for something complex.

Back to our problem.  How do we get 50 general practices organisations to operate as 1?  It is a complex problem.  There is no handbook, because everywhere is different.

That is not to say it is impossible.  What we can do, even operating in the domain of emergence, is understand what factors we need to build in order to give ourselves the best chance of success.  Two stand out.

The first is the need to build some capacity and capability at the collective general practice level.  If general practice is trying to operate as one then whatever forum or entity is trying to bring it all together needs to develop the ability to do a number of things.  It needs to be able to communicate with its 50 organisations.  It needs to be able to coordinate activities across those organisations.  It needs to be able to interact effectively with partner organisations.  These things don’t happen because the different parts of general practice simply meet together.  They need to put in place.

The second is the need to build trust.  Trust is the key ingredient.  If the 50 organisations don’t trust the 1, all is lost.  Here we get into the area of the prisoner’s dilemma, which explains why rational actors won’t cooperate even when it is in their best interest to do so.  Just because it makes sense for general practice to create a single unified voice it doesn’t mean they will do, and in fact without trust it is much more likely that they will not.

It is particularly challenging in general practice because we are all so instinctively independent.  That is why we have 50 different organisations in the first place.  We hate our independence and ability to act autonomously being in any way compromised.  We find working in PCNs difficult enough.  We instinctively pull away from any notion that we might get into scenarios where our practice or PCN has to act for the greater good rather than simply what is best for our practice or PCN.

As we move forward with the 50 to 1 challenge, our approach then needs to be an emergent one, i.e. one where we try things, see how they work, and then adjust accordingly.  We need to keep our eyes on the outcome (why are we doing this), and work hard to build trust and create some capacity and capability along the way.  It might make plan writers uncomfortable, but it is the way forward that will give us our best chance of success.

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