Federations vs Primary Care Networks

There is a tension developing in some quarters between the existing GP federation and the emerging Primary Care Networks (PCNs).  It is like they are trying to compete for the same ground (at-scale general practice), and the result is a growing discord between the two.

A conversation develops about what the federation “offer” is for the new PCNs: will it be for all of the £1.50 per patient running cost, or just a proportion of it?  And what do the PCNs actually get in return for this investment of their money?  Federations can feel they have to justify their offerings, and PCNs can feel they might not be getting value for their investment.

What about the existing work of the federation?  Much of it, such as the delivery of extended access, is funded through monies that in future will be coming through the PCNs.  Will this work continue in its current form, or will the new PCNs demand a different model of delivery to that insisted on by the commissioners?  If it changes, will the GP federation even have a future?

It is easy to understand why tension between the two develops.

For me, however, this tension misses both the point and the opportunity of general practice operating at scale.  Inherent to both PCNs and GP federations is a membership of GP practices (generally the same GP practices).  The point of working together (whether because they choose to or “have to” because of the new GP contract) is to be able to better serve these member practices and their populations.  This is true for both PCNs and GP federations.   The practices are the underlying constant.

So the best place to start the conversation between federations and PCNs is not who should be doing what, and how much they are going to be paid for it, but one between the member practices as to what the relationship between the two is going to be.  The conversation should really be between the practices themselves, working out what they want to do together at PCN level, and what at federation level, and then to organise themselves accordingly.

For me, the most logical step is for the new clinical directors of PCNs to either become the Board, or at least have a majority on the Board, of the GP federation.  This removes the unhelpful sense of competition between the PCNs and federation, and instead enables the PCNs (as the group closest to practices and that hold the majority of the funding) to ensure the federation delivers exactly what the PCNs need.

There is no reason why existing GP federation directors can’t stand and become clinical directors of the new PCNs.  I was asked recently as to whether this would be a conflict of interest.  This question only makes sense if your starting viewpoint is one of competition rather than collaboration between federations and networks.  If the role of the federation is to serve the networks, not only is it not a conflict of interest but it is a pragmatic response to the emergence of PCNs.

For areas that have a GP federation the opportunity exists to have the best of both worlds – scale where it is needed, and a focus on individual local needs.  A GP federation and PCNs working in harmony can secure more investment and resources, create efficiencies by reducing duplication, establish robust and tailored mechanisms for service delivery, limit liabilities, improve patient outcomes, and strengthen the collective voice of general practice.  But whether practices can take this opportunity may depend on their ability to ensure the conversation is focussed on how to deliver the most benefit to practices, rather than one that is competitive between the two.

Primary Care Networks: Learning from the Past

“What has been will be again, what has been done will be done again.  There is nothing new under the sun” Ecclesiastes 1:9.

Primary Care Networks (PCNs) may be the shiny new toy of today, but of course they are not completely new.  At their heart they are about practices working together, about the introduction of new roles, about securing a vibrant future for general practice, about joining general practice more closely together with the rest of the NHS, and about making a difference to local populations.  These are challenges GP practices have been grappling with for a number of years now.

In 2016 at Ockham Healthcare we started the General Practice podcast, and have featured case study after case study of GPs, practices and groups of practices who have been innovating and finding new ways of working to tackle these challenges.

We also published, “The Future of General Practice. Real Life Case Studies of Innovation and New Ways of Working”, in which we highlighted 16 of these case studies, analysed why they had been successful, and distilled the lessons that could be learnt from them. What strikes me now is that this learning is more relevant than ever, to accelerate the progress and impact PCNs are able to make, and to avoid the mistakes of the past being repeated.

The case studies include a focus on introducing new roles.  We considered the impact of pharmacists, first contact physiotherapists, and paramedics, and how they could reduce the workload of GPs.  Even more interestingly, we looked at the development of multidisciplinary teams in general practice, and in particular how in some places they have transformed the management of on the day demand and the whole experience of being a duty doctor in a practice.  Key lessons included starting with the person not the profession, keeping a focus on building a wider team not on individual roles in isolation, and the need to stage appointments of staff over time.

Just like new roles, working with other practices is not new.  There are many experiences out there of what to do and what not to do that those involved in setting up the new PCNs would be wise to pay heed to.  We looked at case studies of mergers over a time period, multiple mergers at the same time, as well as the establishment of a super-partnership.  A whole range of benefits of at-scale working were realised, such as improved resilience, a better ability to manage demand, and greater profitability.  However, we also found simply working at scale does not automatically generate these benefits, and highlighted some important lessons for practices working together to make these a reality.

A key focus of PCNs will be partnering with other organisations, but again this is not completely new ground for general practice.  In the book we considered case studies of practices working with a hospital, with a community trust, with community pharmacy, with the voluntary sector and the local community.  We looked at the benefits general practice was able to achieve through this, such as access to staff, back office support, financial gains, and also what factors seemed to make these particular relationships successful compared to areas where relationships are poor.

There are now less than 75 copies of “The Future of General Practice” left.  To help those who want to learn the lessons from the past as they create the future with PCNs, we are making them available for only £9.99, a discount of over 60%, for as long as stocks last.  Click here for your copy.  The fastest way to success is always to learn first from those who have gone before you.

What is new in the network DES specification and guidance?

Last Friday (29th March) the new Network Contract DES was published.  Six documents in all, and well over a 100 pages of weekend reading (my life is basically one big party).  Much of it restated what we already knew, but I will focus here on the important new things it contained.

There are a number of key changes to the submission requirements.  There has been some talk about the sizes of networks since the new GP contract was published, and how fixed the 30-50,000 population is.  More flexibility is now permitted for the upper end of the range, and where commissioners do agree to larger network sizes, “the PCN may be required to organise itself operationally into smaller neighbourhood teams that cover population sizes between 30 and 50,000”.  There can also be changes to network memberships after the 1st July, but these will require 28 days’ notice, approval from the commissioner, and will only start the quarter after approval is received.

The network agreement now does not have to be submitted by the May 15th deadline, but by the end of June.  Interestingly, it is in a mandatory form (one of the six documents published is the “Mandatory Network Agreement”), a theme reinforced by lines like “we agree that the wording in the clauses to this agreement may not be varied unless a national variation is published”.  There are, however, seven schedules at the end which do allow some variation, and, frankly, seem to me to mean that most networks will need the extended deadline to agree them.  For those interested in hypothetical future scenarios the agreement also includes quite a bit on (amongst other things) the process for leaving/joining networks, expulsion from, dissolution of, and dispute resolution.

More clarity is also provided on who can and cannot be the accountable clinical director.  It can be a clinician (i.e. not just a GP), but they have to be practising within the network area (no out of area leaders allowed).  Four options are suggested for the selection process: election, mutual agreement, selection, and rotation within a fixed term (the latter presumably the last option for those areas where no one is willing to step forward).

What is also new is networks have to be ready to provide extended hours from July 1st, including having in place “appropriate data sharing arrangements”.  If this is done, and the network agreement is completed and signed, the PCN will be considered “established” (a term eerily reminiscent of “authorised” for those still bearing the CCG set-up scars).  Any delays in becoming established will affect payments, most notably the ability to claim the £1.50 PCN funding that will otherwise be backdated to April 1st.

The new GP contract published at the end of January indicated the money for a network could be paid to a lead practice, a federation, an NHS trust or even a social enterprise.  All mention of that is gone in this guidance, which instead states that the recipient of the funding “must hold a primary medical contract” (i.e. a GMS, PMS or APMS contract), thus at a stroke discounting the majority of federations, NHS trusts or social enterprises.

How, then, federations might feature immediately becomes a less straightforward question.  The answer appears to lie in the recently published BMA Primary Care Network Handbook, which suggests one of the potential operating models for networks is to subcontract the provision of services and employment of staff to a federation.  Subcontracting in this way is allowed by this guidance, as long as it has the consent of the commissioner.  There is some complicated VAT guidance also provided, but my take is that as long as the twin traps of simply providing employment of staff (so falling foul of agency requirements) and of separating out clinical and non-clinical services into separate contracts, are both avoided then subcontracting by the networks to the federation is unlikely to incur VAT.

One of the other questions that has been doing the rounds is whether there is financial benefit in networks being smaller to secure proportionally more resources.  I think this guidance effectively puts that to bed by clarifying that even though each network (regardless of size) will initially receive 100% funding for a link worker and 70% funding for a clinical pharmacist, from April 2020 each network will receive a “single combined maximum sum… based on weighted capitation”.  So any advantage gained in 19/20 will be immediately lost the following year by having less left to spend on new roles the following year.  Indeed, the guidance states, “PCNs will not wish to make short term gains to the detriment of longer term sustainability”.

However, in 2019/20 practices can only use the workforce funding to appoint a link worker and a pharmacist, and cannot use the funding for any other roles.  The only flexibility is if a network either cannot recruit to one other of these posts, or already has a “full complement” of one or the other, at which point networks can substitute between the two roles.  The workforce funding for PCNs also means the clinical pharmacist scheme in general practice is being ended.  This means if practices have applied to the scheme, or even been approved for it but have not appointed a pharmacist, they will not now be eligible to go ahead.

The guidance also introduces the concept of “additionality”.  Essentially a baseline of staff numbers supporting practices across the five roles (clinical pharmacist, link worker, physician associate, extended scope physiotherapist, and paramedic) as of 31st March this year will be taken through a combination of NWRS (national workforce reporting system) and a (mandatory for practices) survey by commissioners during April 2019.  The funding for additional staff will be given as long as networks can show that these staff are “additional” to this baseline number.

There is much in the guidance about the supervision and workload requirements of the new staff.  My worry is the level of restriction in the guidance, coupled with the cost pressure and associated liabilities each new member of staff funded at 70% (or less) of total cost presents, may lead to a much lower uptake in the recruitment of the new staff than those writing the guidance are seemingly predicting.

Overall, as is the tendency of all detailed guidance, whilst it may provide some much needed clarity, enthusiasm for the changes will inevitably be dented by the sheer weight of the new instructions.  While some aspects are helpful, some are clearly not e.g. the change to the hosting arrangement options, and the lack of flexibility around workforce funding.

At the heart of the new GP contract was a desire to create a sustainable future for general practice, and yet what seems to be most lacking in this guidance is any focus on how all of this will benefit core general practice.  The challenge for local leaders will be first to understand this guidance, but then, more importantly, to translate it in a way that can still inspire local GPs and practices to make the most of this new opportunity.

How can Federations help Primary Care Networks?

Amongst all the furore that primary care networks are creating it is easy to lose sight of GP federations. The role of federations in the new world of primary care networks is unclear and not prescribed. So do they really have a future? If they do, what will it be? This week, I explore how federations could help the nascent primary care networks meet four of the biggest challenges they face.

Challenge 1: Managing the new clinical staff and the associated liability

By 2024 a typical (50,000 population) primary care network will have 5 clinical pharmacists, 3 social prescribers, 3 first contact physiotherapists, 2 physician associates and 1 community paramedic. That is a lot of staff. Who is going to manage the employment risk (and associated liability) for these staff? Some will arrive with considerable amounts of NHS service, making the potential employment liability very high.

Federations established as limited liability vehicles can not only take this risk away from GP partners, but can also add real value to the recruitment, management and development of these staff. When multiple networks are seeking to recruit from this limited pool of new staff, why will they select one area over another? If a federation can offer peer support, professional development, and (probably most importantly) structured support for both practices and staff in the implementation of these new roles, they will make their area more attractive to these staff, as well as ensuring the networks gain the greatest possible benefit from them. It is hard to overemphasise the importance of change management support to go alongside the recruitment of these new roles.

Challenge 2: Maximising the available financial resources and minimising the financial risk to practices

The new GP contract suggests that a typical network will have funding for additional role reimbursement of £726,000 by 2023/24. At 70% this creates a potential cost pressure for networks of up to £311,000. As a side note it has been suggested (e.g. in the BMA primary care handbook) that the £1.50 management allowance could be used to offset this, but the total management allowance for a 50,000 network is £75,000 – well short of the total amount potentially required.

It is on the finance side and meeting the “30% challenge” that federations can really come into their own. Federations can:

• Limit liabilities through an incorporated structure
• Attract further investment. Many CCGs and local integrated systems will want to invest in general practice, but will want to do it at a scale that maps to boroughs or historic commissioning areas, and federations providing an infrastructure across multiple networks will be an attractive vehicle for them to do so.
• Make the £1.50 management allowance go further. A typical network can’t hope to include delivery support, administrative support, communications and engagement, HR, financial support and leadership support with £75,000. But multiple networks working together could easily do this.
• Create other economies of scale. The £6 per head for extended access is a great example of a resource that if used collectively across a wider area through a federation could generate a significant return to constituent networks.
• Establish strong financial governance. A small but effective finance team within a federation can ensure financial risks are minimised, financial efficiencies are delivered (e.g. in relation to what funding is superannuable), and income opportunities are maximised.

Challenge 3: Ensuring delivery both across practices and with other organisations

Networks are not simply constructs that need to be created. There is a delivery expectation upon them, both across constituent practices and with local organisations. Five new network specifications kick in in April 2020, probably alongside the requirement to sort out extended access, plus any local enhanced serviced the CCG may want to add in to the mix. How will one network operating on its own get its head around all of the new delivery requirements? The nature of the new specifications mean it will not be as simple as passing them on to the member practices and simply asking each to do its share. New delivery models will need to be developed, agreed with practices and local organisations, and implemented.

It may be on the delivery requirements of networks that federations can add the most value. Resources can be dedicated to each of the network specifications, for example a clinical lead and a lead manager for each, who can negotiate with local practices, organisations and commissioners to create locally-tailored delivery models. Sharing resource and expertise in this way through a federation can reduce duplication and enhance local delivery.

Challenge 4: Meeting the leadership challenge of networks and creating a powerful local voice

Much is expected of the new “accountable” network Clinical Directors. They are to become the voice of the network in the plethora of integrated care meetings locally, as well as leading the development and delivery of new services, and sorting out any inter-practice issues – all in roughly one day a week. Nationally we have heard of a desire for new leaders to emerge from practices to take on these roles. These could be very challenging and isolating roles for potentially inexperienced leaders.

Networks operating together within a federation can do a number of things. They can provide leadership development. They can ensure the leaders work together to support each other, and share ideas, approaches and learning. The incessant representation requirements from the wider system can be prioritised and shared across the group. Equally, a strong collective voice for primary care and the area can be established through a federation (whereas multiple network voices, potentially contradicting each other, is likely to weaken the overall general practice system voice).
Primary care networks are not in competition with each other, and working together through a federation can help meet some of the major challenges they will inevitably face. It does of course rely on trust, and a belief that the federation will operate to serve and support the new networks. It may be that governance changes, such as ensuring there are at least a majority of network clinical leads on the federation board, are needed to establish the future role of the federation in support of networks. But however it is done, it does seem there could be a very important role for federations in support of general practice as we move into the new world of primary care networks.

The new BMA Primary Care Network Handbook

More information was recently published by the BMA on primary care networks.  You can read it here.  I would regard it as essential reading for all GPs and practices who are considering joining a network.   But at 30 pages it takes some working through, so for the time poor I have summarised below what it says about the questions not answered in the initial contract document.  The answers provided are essentially quotes from this new BMA handbook.

Can CCGs influence the shape of the new Primary Care Networks?

The only involvement of the CCG in this process should be when there are gaps in the total PCN coverage of their area. (the document’s highlighting, not mine)

The content of the network agreement is not within the remit of the CCG to challenge. As long as the practices have agreed, the CCG cannot refuse the DES based on its content.

What agreement is required between practices in a network by 15th May?

To be recognised as a PCN, individual GP practices will need to make a brief joint submission outlining the initial network agreement signed by all member practices.  This will specify how the member practices will handle network-specific issues such as:

  • decision making, governance and collaboration arrangements
  • arrangements regarding the delivery of different packages of care
  • the agreement for distribution of funding between the practices
  • arrangements regarding the employment of the expanded workforce
  • internal governance arrangements (appointment processes, decision making process, etc).

Who can be clinical director of a primary care network? Does it have to be a GP?

It is expected that the clinical director will be selected from the GPs of the practices within the network, but any appropriate clinically qualified individual may be appointed.

While there is no requirement for the clinical director to be appointed from within the network, we recommend that the first option should be to consider an appointment from within.

How will Primary Care Networks make decisions?

Each network is to have a governing/representative body.  This network “board” should operate as the network’s governing body, bringing all members together, overseeing joint decision making, the strategic direction of the network and the network’s funding/financial layout. It is also the body to which the clinical director would be directly accountable.

The network will need to decide:

  • what is within the remit of the clinical director to act executively, what needs to go back to the practice representatives
  • how the governing body makes decisions – does it require a simple majority, a conditional majority, unanimity, etc
  • how often the governing body should meet
  • how meetings are chaired (an elected chair, rotational chair, etc). As the clinical director will be accountable to the governing body, it may be better for the role to be excluded from chairing the governing body

What will the operating model of Primary Care Networks be?

Key issues to consider when establishing an operating model include employment liabilities, ability to offer NHS pension, and inadvertently attracting VAT charges.

5 potential operating models for networks:

  1. “Flat practice network” – practices work together and spread responsibilities and commitments, with one practice acting effectively as the network bank account.
  2. “Lead Provider” – a lead practice takes responsibility for engaging the workforce and entering into contracts
  3. “GP Federation/Provider Entity” – the provider entity is subcontracted to deliver services required by the DES and to employ the staff
  4. “Super-practice as a network” – a super-practice creates an internal ‘network’ amongst its constituent sites, with each ‘neighbourhood’ of practices operating as a mini network in themselves.  The super-practice would be the nominated payee and would then supply support and resources to its constituent neighbourhoods.
  5. “Non-GP provider employer models” – the non-GP provider is signed up to the network agreement, along with the GP practices. They provide network services and employ staff available under the DES on behalf of the network, as well as using their own staff to further enhance the network’s potential workforce.

All primary care networks will need management and administrative support structures.  Practices that form the network will also need to seek advice on any proposed legal agreements and financial matters, and will need to establish a regular meeting of their representatives to ensure that things are developing as planned.

What will Primary Care Networks actually do?

Networks will develop expanded practice-based and connected teams to deliver the provision of workload support of the member practices by:

  • working alongside the existing practice team and taking responsibility for some services of the member practices (to be decided by the network), focusing on extended-hours delivery in the first instance
  • restructuring some service delivery (to be decided by the network)
  • offering access to the extended PCN team (extending the workforce).

The funding currently associated with the Extended Hours DES will transfer (with the associated responsibilities) to the network. This will be provided as an entitlement to the network’s nominated bank account of £1.45 per patient. The network will decide how this funding is distributed in line with the provision of services required to fulfil the requirements of Extended Hours.

The £6 per patient that is currently provided for the Extended Access scheme will also transfer to the networks; the exact timing of this transfer will depend on the current arrangements in each area for the Extended Access scheme… The intention is to bring together extended hours and extended access activity to reduce fragmentation and confusion for practices and patients.

How will the funding for the new PCN workforce role work?  Will smaller networks receive (proportionally) more funding?

There will be funding for the clinical lead post for each network on a basis of 0.25 WTE per 50,000 patients, at national average GP salary (including on-costs) (of £137,516).

For the first year of the DES (2019/20), every network with a population of at least 30,000 can claim 70% funding as above for one additional WTE (whole time equivalent) clinical pharmacist and 100% funding for one additional WTE social prescribing link worker.

The level of funding available for a PCN will scale with its size. This will be especially true in future years when workforce funding switches from direct reimbursement to a capitated payment, based on the population size of the PCN.

Over the coming years…the workforce reimbursement system will be altered so that it is linked to the patient population of the PCN.

The network will need to provide a monthly invoice with evidence of costs to its CCG, and will be reimbursed the required amount up to the maximum reimbursement. The maximum reimbursable amount for each of these roles will be set at the weighted mid-point of the respective Agenda for Change salary band.

There are no mandated contractual terms for staff employed under the PCN DES.

Can the funding be used for additional staff practices have already employed?

Staff employed under the DES must be ‘additional’ to the existing workforce employed by the network’s member practices. This will be measured on a 2018/19 baseline established as of 31 March 2019…The only accepted exception will be those clinical pharmacists employed via either the national Clinical Pharmacist in General Practice scheme and Pharmacists in Care Homes scheme.

How are practices expected to fund the 30% staff costs (for roles where only 70% funding is provided)?

2 options:

  • Use the network payment (e. the £1.50 per head).
  • Practice-pooled funding (e. contribution from each practice)

Who will be responsible for distributing the network funding?

How funding could flow in a network – 4 examples:

  1. “Flat practice model” – expenses shared across member practices
  2. “Lead practice model” – a single practice takes sole responsibility
  3. “GP federation/provider entity” – the limited liability provider entity takes responsibility
  4. “Non-GP employer” – the non-GP healthcare provider takes responsibility

Can my CCG decide not to provide the required funding for networks?

Commissioners cannot remove or reduce the entitlements, but they can add to them.

Commissioners may choose to transfer, where appropriate, their locally commissioned services contracts to the network, rather than with individual providers.

Are Primary Care Networks just a precursor to general practice becoming part of Integrated Care Providers?

A more controversial model of integration, the ICP (Integrated Care Provider) has also been introduced by NHS England. ICPs involve merging multiple services into a single contract, held by a single provider. ICPs have been subject to controversy and the BMA has been clear that we oppose their introduction, as they increase the risk of privatisation and are incompatible with the independent contractor status of GPs.

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