Do PCNs need a manager?

In the update to this year’s GP contract the increase in funding for additional roles for PCNs from 70% to 100% was heralded in this way:

We have heard that the £1.50/head support for PCNs – worth £72,000 annually for an average PCN – has been deployed to contribute to the 30% funding of additional roles.  Instead it can now be used as needed for development and transformation support.  It equates to a full-time band 8A, and increasing the contribution of Clinical Director time by almost 50%.  We encourage Clinical Directors to use the funding to ensure sufficient support as rapidly as possible”.

A band 8A manager, for those not fully conversant with NHS pay scales, attracts a not insignificant salary of between £45,753 and £51,668.

Some PCNs have taken the plunge and employed a manager.  Others are more reticent.  The relative ease with which the PCN requirements were able to be handled in 2019/20 meant many PCNs decided to return much of the (unused) £1.50 to practices at the end of the year, and in doing so set a precedent that some PCN CDs are now uncomfortable breaking.

Part of the problem of course is that a salary of c£50K for a PCN manager is significantly higher than the salary of the average practice manager.  On the one hand, PCN CDs don’t want to be accused of stealing practice managers from local practices, and on the other it is very hard for a manager with no local knowledge to come in and work effectively across practices.  Especially when the local PMs know exactly how much the incoming PCN manager is being paid…

It is very difficult for an outsider to come in as manager and be effective straight away with a group of practices.  This requires trust, which needs time to build, and the covid restrictions make that all the more difficult right now.  It is hard to build relationships via Zoom.

Do PCNs really need a manager?  Is it worth the investment?

Many PCNs have been able to cope perfectly adequately without one until now.  Unfortunately this is no great indicator that this will be the case in future.  On October 1st three new service specifications kick in for PCNs (care homes, medication reviews and supporting early cancer diagnosis), alongside the requirement for PCNs to offer a social prescribing service.  In addition, the new Investment and Impact fund (think PCN QOF) begins.

In six months’ time four more service specifications will need to be delivered, while at the same time PCNs will take on the responsibility for delivering extended access.

Many PCNs are currently recruiting an average of 10 staff, with another 6 or 7 to be recruited by the start of next year.  These staff will generate work, headaches and challenges (new staff always do), and someone will need to pick up the pieces.

Without a PCN manager, who is going to do all of this work?  This is without mentioning the plethora of system meetings (just say no), the data sharing and patient engagement requirements, and any local initiatives the PCN has committed to.  Is the PCN CD expected to do all of this in 2 or 3 sessions a week?  Or the PCN practice managers in their spare time?  I don’t think so.

If your PCN does not yet have a manager in place, the time has come to bite the bullet and recruit.  From October not having a PCN manager will cost more than having one.  Don’t put it off any longer.  Some practices might not like it, but the sheer scale of work means that PCNs will not be able to function effectively without one from October.

Why Flu Planning is So Difficult this Year

There cant be anyone working in general practice who has not yet been asked what their plans are for the flu season.  But I am not 100% sure those asking always understand why the question is so difficult this year.

We are still very much in the planning stage, as we await the arrival of the first vaccines.  It is difficult to know how well prepared practices are, but what is certain is preparations are much more difficult than in previous years.

In part this is because of national shifting sands on three fronts: the cohorts to be vaccinated; the PPE requirements; and getting hold of the vaccines.

The season started with a message that 50-64 year olds are to receive the flu vaccine this year.  This was then changed to a message that this will only happen later in the season, if vaccine supplies allow.  So now we have a vocal cohort of individuals contacting practices demanding a vaccine that practices won’t be paid to administer, and confusion across practices as to exactly what they are supposed to be doing.

Initially the PPE requirements were a face mask for every session, with new gloves and apron to be worn for each patient.  Once forward thinking practices, PCNs and GP federations had dutifully mass purchased the required equipment, the guidance was changed so that only sessional face masks are now required.  And who knows whether it will change again in future.

As for vaccine supplies, no one knows how that is supposed to work.  Because practices generally order vaccines a year in advance, the orders placed are for the normally expected amounts.  This would be 50-55% of a practice’s usual cohort, which means practices are well short of the 75% needed to achieve the target, even before this year’s additional cohorts are added on.

Anyone who has tried to order additional supplies will know all remaining vaccine stocks are being purchased centrally.  What we don’t know is how any central supply will work in practice, and how these vaccines will be distributed to practices.  But given the recent experience of central purchasing and distribution of PPE, it is not surprising there is little confidence amongst practices that this will work well.

However, these are not even the biggest challenges practices face in developing their flu plans.  Traditional systems of flu delivery (bringing in large numbers of patients over a weekend or two) simply will not work this year.

The social distancing requirements mean that patients need to be given more specific appointment times, and the usual method of “stacking” multiple patients at once cannot be used.  The high DNA rates that can usually be offset using this method will have a significant impact.  Practices will also need additional staff to ensure social distancing standards are adhered to and manage any queues that form.

At the same time, the social distancing and PPE requirements mean that clinicians will be able to vaccinate far less patients per session.  I have seen the overall impact of this estimated at a vaccination rate of one patient every six or even eight minutes, compared to one roughly every two minutes in previous years.

What this means is that practices can see less patients in a session, but with higher staff costs.  The net impact has been estimated as meaning that the costs of vaccination will rise by between £6 and £9 per patient.  This of course calls into question whether practices can even carry out the vaccinations this year for the fee that is being offered (which currently remains unchanged from previous years).

This is why flu planning is so difficult this year.  I am not sure the system fully yet understands the extent of the challenge this creates for general practice, but I suspect when we move from the planning to the delivery phase these challenges will become much more evident.

Start Recruiting 2021/22 Additional Roles Now

We have all been struggling to get our heads around the Additional Role Reimbursement Scheme (ARRS) for PCNs, and in particular how to make most of the opportunity it creates.

Significant changes were made to the ARRS in the 2020/21 GP contract (in particular the increase in reimbursement from 70% to 100%, and widening the number of available roles to 10).  However, the impact of these changes were somewhat lost initially, as a result of uncertainty as to whether PCNs were going to sign up to the revised DES and, of course, the emergence of coronavirus.

But now PCNs are moving forward as quickly as they can with their recruitment plans.

The problem is, despite an apparent enthusiasm nationally for each PCN to use all of its ARRS fund to be used, the rules seem to conspire against this happening.  PCNs can only be reimbursed up to a maximum monthly reimbursable amount, which means funds can only be used once the new staff are actually in post.

In order to spend all of the money PCNs would have needed their new staff to be in post on the 1st April.  But given at that point most practices had not even signed up to the DES, not to mention the distractions posed by the small matter of a pandemic, it is not surprising that for many PCNs staff are only being recruited now.

It seems likely (and entirely reasonable, given the PCN DES specifications only start on the 1st October) that the majority of the new PCN roles will probably not be in post until October.  And if the PCN staff do not start until October this means somewhere in the region of half the available ARRS money will not be spent.

How then can PCNs ensure they make the most of the available ARRS fund for this year?

The best way is for PCNs to start their recruitment to their 2021/22 roles now.  PCNs can use the underspend against this year’s roles to pay for additional months of next year’s roles.

The “average” PCN has £344k available for additional roles this year.  This goes up by nearly 75% to £597k next year.  Even a PCN that is on track to spend as much as 70% of its funds this year could still afford to have all of its roles for next year start in the middle of November this year, and remain within budget this year and next.

This means, taking into account the need for notice periods and the delays these cause to recruitment, PCNs who want to maximise the use of their allocation would be wise to start their recruitment for next year now.

One caveat of course is that paramedics and mental health practitioners cannot be employed until April 2021.  These roles will be popular, so even for these it is worth considering starting the recruitment process at the end of October/early November so that they are recruited and ready to go on April 1st 2021.

Even for those PCNs who did manage to get ahead of the curve and are not looking at much of an in year underspend, it is still worth being ready for early recruitment to next year’s roles.  It is highly likely your neighbouring PCNs will have an underspend (because the majority will), and the rules are that any underspend in an area should be offered in the first instance to the neighbouring PCNs, rather than being lost to general practice.

PCN recruitment may have got off to a slow start this year, but I suspect this wont be the same in the years to come as savvy PCNs get started well before the next year begins!

How to Create Effective Representation for your PCN

We are getting into the weeds a little bit this week, as we consider what action PCNs can take to ensure they are represented effectively at system meetings.

Regular readers of this blog will know that we have established two important principles when it comes to PCNs attending the wide range of system meetings that they are currently being invited to.  The first is to prioritise local PCN delivery over attendance at these meetings.  The second is that finding effective representation is difficult.

The way to think about this is not to consider first who should represent the PCN, but instead to start by considering how to create the representation the PCN needs.

One of the actions very few of us take (but is really important) is to determine what outcome we want from a meeting before we attend.  Why are we going?  If we are clear what outcome we want from a meeting we can in turn be clear with others who attend for us the outcome we are asking them to achieve.

A set of outcomes our PCN might be looking for in attending a system meeting might be:

  • To increase the resources and opportunities coming to the PCN and its member practices
  • To enable the appropriate shift of work (and resources) from secondary to primary care
  • To accelerate the alignment of community services with the PCN
  • To raise the reputation of PCNs and build confidence that they are an effective delivery vehicle

Whatever they are, they need to be ones appropriate for the meeting and for your PCN.  Of course, if your PCN has already taken the time to be clear about its purpose, then the outcomes may well be a version of the those stated in the purpose of the PCN.  Equally, if when you think about a meeting you cannot come up with any outcome you want to achieve by attending, that is probably a sign that you don’t need to go!

The reality is that all of us get invited to meetings when we are not clear what the meeting is or why we are needed.  For the time-poor PCN CD it is far better to spend time seeking clarity on exactly why attendance is required and the outcomes that attendance is seeking to achieve, as opposed to turning up and hoping that clarity will come during the meeting itself (it rarely does).

When we are clear on why we are attending a meeting, the question of representation becomes much easier to handle.  If you can be clear with your representative on the outcomes you are seeking to achieve, they can be much more confident in representing you in the meeting.  This will apply to a non-CD attending for the PCN, or for the CD of another PCN representing your PCN as well.

You can even go as far as being clear what they can or cant agree on your behalf.  For example, anything in line with the outcomes can be agreed, but anything that commits the PCN to additional work has to come back to the PCN for a discussion.  It is perfectly reasonable for a representative to gain rapid agreement after a meeting from those not present, and should not feel pressured into feeling they have to make decisions for others there and then.

We often get lost in the question of who should represent us at meetings (and whether we trust them or not).  But our time would be better spent on why attendance at each meeting is important, and as a result being clear on what the representation is we require.

Who can Represent my PCN?

I wrote recently about the importance of PCNs prioritising delivery over attendance at meetings.  The question that poses is how PCNs can ensure they are effectively represented at meetings if they are not there themselves.

First off I would just reiterate that given the limits of available PCN time, if a PCN is faced with a choice of either ensuring local delivery or attending a system meeting, I would always prioritise the former.  But how then do we ensure that the PCN influence on decision making is not completely abandoned?

This raises the thorny issue of representation.  While the idea is simple enough – one person goes to a meeting to represent a PCN or multiple PCNs – the reality is much more difficult.  How do I and my PCN know that the person who attends on our behalf is going to accurately represent us?  How can we be sure that by not attending the meeting we are not missing out on opportunities and/or resources?

Representation requires trust.  And the trust required for representation is hard to gain.  If I am to trust someone to represent my PCN I am not simply asking for the minutes of the meeting to show that my PCN turned up, or someone to spectate and then feedback afterwards.  I want, in addition to timely and appropriate feedback on the meeting and any relevant decisions made, to:

  • Know that my PCN is going to be represented accurately
  • Be confident that the representative is not going to put his or her own interests before that of my PCN
  • Believe that the reputation of my PCN will be strengthened as a result of my representative’s attendance
  • Trust that the representative will make an intervention where one is required, e.g. because the meeting is suggesting something inappropriate/absurd/potentially damaging etc.
  • Be sure that the opportunity to build relationships with other attendees will not to be lost

Given the challenge that effective representation presents, how is a PCN to find someone they can trust to represent them?

A commonly suggested solution is to use rotation, either between CDs of different PCNs, or between members of a PCN, where a group of individuals take turns to be the representative.  This stops everyone needing to go, and reduces the risk of any bias to a particular individual or PCN.  However, I don’t like this as a solution.  Meetings themselves are about relationships.  In any regular meeting the attendees get to know each other and find a way of interacting.  If my representative is always someone new they wont understand the dynamics of the meeting and as a result will almost certainly be less able to influence any outcomes.

This then leaves the daunting prospect of me needing to find a single individual to represent me and my PCN at the meeting.  Who can I turn to?  Here we are talking primarily about system meetings, with potentially Board Directors of the CCG, hospital and community trust in attendance.  So in addition to being someone that I trust, I also need someone with an understanding of the system, someone who can hold their own in that company, and someone who can influence the outcomes in at least the same way as I believe I could if attended in person.

The horns of the dilemma facing many PCN CDs then is who can represent me and my PCN at these meetings that I simply don’t have time to attend?  And the default response is generally that there is no one, and that I will just have to find time and go myself.  But then, as I discussed last week, the PCN loses out because delivery suffers as there is insufficient time to both deliver and go to these meetings.

In many ways this brings us back to where we started.  If the choice is delivery versus meetings, choose delivery, and say no to the meetings.  But the real question is not is there someone who can represent me, but how can I create the representation that I need.  That is the question that I will explore in more detail next week.

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