First steps towards networks

Maybe your practice has never worked well with other practices.  Maybe you have avoided it, as far as has been possible.  The new GP contract, with so much money going through the new primary care networks, means this strategy of avoidance is not going to be an option any longer.  What do you do now?

There is a perception that primary care networks are not really anything new, that they have been happening anyway.  I don’t think this is true.  According to the NAPC website, 16% of the population is covered by the forerunner of primary care networks, primary care homes.  NHS England state that according to CCG returns 80% of practices report being in some form of network.  A generous estimate might put the real figure of the percentage of practices that have actively sought to work with their neighbours in some sort of meaningful way in the middle of these two, which would be about 50%.

That means half of practices are in the situation of having to work with other practices for the first time.  It means while half of the practices are building on some sort of foundation, making progress, and generally intimidating those who don’t know what to do, half are simply trying to get their heads around what the new world of networks means.

I have spoken to a number of people recently, asking what advice they would give to GPs and practices in exactly this situation.  I asked an accountant, a lawyer and the Head of Primary Care at NHS England.  Interestingly, all three came up with exactly the same answer.  Go for a drink or for a meal with your local practices.  Get to know them.  Build the relationships.

The questions GPs and practices ask when reviewing new guidance or documents such as the new GP contract are often technical.  What will the accounting relationship be between the new network and my practice?  Will we incur VAT charges?  Who will employ the staff, and where will the risk sit?  These are all valid questions, but, even according to an accountant and a lawyer, they are not the place to start.

A few years ago a colleague of mine took up a new post as an Executive Director in a large teaching hospital.  On her first day she met with the CEO.  He said to her that he didn’t want her to do anything for the first month, just to build relationships.  She was stunned.  She wanted to prove her worth, and was worried that she would be seen as someone without focus on delivery.  But years later she reflected it was the best advice she could have been given.  She said too many people start to try to do things without having relationships in place.  Delivery then happens at the expense of those relationships, not through them.  But because she was given the time to develop strong relationships she was able to deliver far more than if she had just jumped straight in.

The same applies to GPs and practices looking to set up new networks.  The whole rationale of the 30-50,000 population size is about relationships.  It means the people operating within the network can all get to know each other and have a personal relationship, and not be of a size that inevitably creates distant, faceless bureaucracies.  So if the basis of the new primary care network is relationships, the best starting point is to build these relationships.  While it might feel indulgent when the timescales are short, time invested now will repay in buckets in the months and years to come.

Primary Care Networks: Start with the right question

The clock is already ticking. Following the recent publication of the new GP contract, GP practices only have until the 15th May to submit their network registration information to their CCG. Waiting until the Network Contract DES is published (promised by 29th March) will only leave 6 weeks. Starting now gives practices three months to get ready for the new networks.
But where to start? It is tempting to jump straight in to what the network will look like and how it will operate. But a better place to start is with “why?” Why will this network exist? What is its purpose? What difference is it going to make?

Simon Sinek talks about this lot. His book, “Start with Why”, has inspired many. For the time poor, you might want to cut straight to this 5 minute short version Ted talk to understand the essence of it. Essentially, people are inspired by a sense of purpose. It is this that motivates us to take action. Clarity on why we do things leads to much more sustained action than clarity on what we are to do or how we are to do it.

The GP contract offers a number of possible motivations for primary care networks. They are (p25):

  • “Intended to dissolve the historic divide between primary and community services”
  • “A way of helping GP partnerships survive and evolve over the coming decade, and provide a means of mutual support for better workload management”
  • “A dedicated joint investment and delivery vehicle”, a way of enabling investment into primary care where it cannot reasonably be expected for every practice to deliver the requirements on their own”
  • “Large enough to run a full multi-disciplinary team”, a way of bringing new roles into general practice”
  • “A clear geographical locus for improving health and wellbeing”
  • “To provide strategic and clinical leadership to help support change across primary and community health services”

Each area is different. One, some or all of these may work for you. More likely there will need to be some adaptation, some local tailoring, to create an ambition that is inspiring for your GPs and the practice staff in your network.

It will be easy to get lost in creating a network simply because you have to. Or in tactics to try and maximise income received. Or in the details of how the network will operate. But networks present a huge opportunity for general practice, not just for now but for many years to come. Decisions made in the next 3 months are like to have long lasting consequences because these networks will grow in importance.

Even though time is short, time invested now in determining the why of their network for member practices will be time well spent. It will create unity, excitement even, and a shared sense of purpose. It will make delivery down the line much easier, and sustain action well beyond the initial network submission deadlines.

The GP Forward View and the new GP Contract: Spot the Difference

On the surface the new GP contract and the GP Forward View (GPFV) appear very similar.  Both contain promises of money and staffing, as well as a determination to create a sustainable future for general practice.  But nearly three years on from the publication of the GPFV, things don’t feel much better.  Workforce, finance, workload and morale all remain challenges for general practice.  Will it be any different this time round?  We’ve been examining the differences between the two documents, and have identified 5 that give cause for optimism.

  1. Type of document

While both are written documents, there is a big difference between the GPFV and the new GP contract.  The GPFV was essentially a commissioning plan – it was how NHS England, as the commissioner of general practice, was going to improve it.  It was full of aspiration, but lacking in detail of how it was going to be delivered, a concern that ultimately proved well-founded.  The new GP contract, however, is just that – a contract – and as such is clearer and more transparent, making the promises feel much more concrete than in the GPFV.

  1. Money

On the surface the promise of money is similar.  In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years.  The problem the GPFV ran into was transparency in relation to the money.  The RCGP and others set up tracking mechanisms to try and check the promises made were being adhered to.  In the end, because the £2.4bn was actually to be delivered over 8 years (a retrospective starting point of 2013 was used), and because a huge chunk of it went on access and so not to core general practice, it never made the difference it should have.  The new contract is different.  Yes £1.8bn of the £2.8bn comes via the new networks, but it is still coming to practices, and how the money will be delivered is clearly laid out.

  1. Implementation

Money in the GPFV came via NHS England to CCGs, sometimes to federations, and eventually to practices.  Multiple pots all had their own application processes.  The money proved difficult to access and was beset by bureaucracy.  This time the money will come via the contract, either directly to the practice or directly to the network set up by the practice.  It feels like control of the funding will sit at practice level and then work up, rather than (as with the GPFV) start at the top and slowly trickle down.

  1. Policy Objective

Politicians and commissioners always want a return for their money.  In the GPFV the primary policy objective was extended access (‘we will invest this money in general practice if you deliver 8-8 working 7 days a week’).  The introduction of access stretched the already-thin workforce even further, diverted portfolio and part-time GPs away from core practice, as well as moved funding thought to be for core general practice into private providers.  In the new contract the primary policy objective is the introduction of primary care networks.  These networks are to enable general practice to integrate more effectively with the rest of the system, and allow a more robust system of out-of-hospital care to be created.  The great news for general practice is that, done well, these networks can support and enhance the delivery of core general practice.  This alignment of the needs of general practice with overall policy provides maybe the greatest hope for the new contract.

  1. Workforce

One of the biggest failings of the GPFV has been its inability to successfully tackle the workforce crisis in general practice.  The service is still waiting for 5,000 of the promised 5,000 additional GPs.  The new contract, however, takes a more realistic approach.  The focus on new GPs isn’t lost, but is enhanced by a much more pragmatic (although still challenging) plan to recruit 20,000 additional non-GP non-nurse clinical staff, with the funding being directly provided to the practices via networks.  This realistic plan for staffing creates a strong foundation for optimism.

The Obsession with Access is Destroying General Practice

If you ask the government what is important about primary care, it is clear there will only be one response: access.  Access is determined to be important to voters, and so it is access politicians care about.  Whatever the cost to general practice itself.

Looking back to 2016, the GP Forward View feels very much like a solution to the strong governmental desire to introduce extended access, despite the crises befalling general practice.  Here is a headline £2.4bn…with the condition you deliver extended access.

Indeed, recent reports suggest a huge investment in recent years into general practice.  This is not what it feels like to practices.  Much of the investment never reached practices, but instead went to extended access providers.  As these providers deliver general practice, it all “counts” as investment in general practice.

The reality is, of course, that the introduction of extended access has made things worse for practices.  The root cause of the workload and financial problems, alongside the inexorable rise in demand from a growing, ageing population, is the lack of GPs.  Fewer GPs means more work for those who remain, plus an increased expenditure on locums which in turn creates a huge financial pressure on practices.  The introduction of extended access simply creates an additional demand for GPs, stripping down further the numbers who can work in core, in-hours general practice.

The pledge to increase the number of GPs by 5,000 was a central part of the GP Forward View.  But despite an increase in the numbers entering training, the numbers leaving has exceeded those arriving.  GP numbers (FTE excluding locums and registrars) fell 3.4% between September 2016 and September 2018.  The pledge to increase access to 8am to 8pm seven days a week, on the other hand, has been delivered.

What, then, do we get in the Long Term Plan?  Yet another access pledge.  “Digital first primary care will become a new option for every patient improving fast access to convenient primary care.  Some GPs are now offering their patients the choice of a quick telephone or online consultation…. Over the next five years every patient in England will have a new right to choose this option – usually from their own practice or, if they prefer, from one of the new digital GP providers” (Long Term Plan 1.44, p26).

So now, in addition to GPs who choose to work extended access hub shifts (convenient, without the pressure and hassle of core general practice), we are going to have GPs who choose to work for “one of the new digital GP providers” (potentially ‘working from home’ for GPs).  Further dilution of a precious and diminishing workforce, all in the name of access.  All piling yet more pressure on a general practice that is creaking at the seams.

Amidst the plethora of documents that have come out already in 2019 (with potentially the most important, the new GP contract, due this week), there is one ray of hope.  Dr Nigel Watson’s Partnership Review did explicitly recognise the pressure access is causing core general practice.  His recommendation 5a states, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends” (p32).  He explains, “Extended access services in many areas are attracting GPs away from practices. NHS England should therefore consider how existing funding for extended access and opening could be allocated through PCNs as they mature, to enable local decision making on managing demand appropriately. This should also support partnerships to feel a greater sense of control and influence over managing the safety of their working day.  It could also reduce fragmentation of services and increase opportunities to improve continuity of care.

It is not a recommendation, however, that has been picked up in the Planning Guidance or the Long Term Plan.  Whether it will turn into anything remains to be seen, but the priority this government has placed on access to primary care, regardless of the consequences for core general practice, makes me, for one, sceptical as to its chances. However, it is certainly a recommendation fledgling primary care networks would do well to remember as they move forward, as its chances of implementation probably relies on pressure from them.

BMA Council Chair Chaand Nagpaul summed it up well when he said, “There is no use opening the digital front door to the health service if we don’t have the healthcare staff behind it”.  The current obsession with access is dangerous, because it is making a bad situation worse.  A resource can only be stretched so thinly, and it is only a matter of time before more holes begin to show.

Primary Care Networks are the new black

Reading the NHS Long Term Plan (LTP), the GP Partnership Review, and the Planning Guidance for 2019/20 (not something I would recommend for a single sitting!), one thing stands out for general practice above everything else – Primary Care Networks.  When it comes to general practice, the documents make it clear that Primary Care Networks, based on neighbouring GP practices that work together typically covering 30-50,000 people, are the new black.

They are seen as the enabler of “fully integrated community based healthcare” (LTP p15).  They will have expanded neighbourhood teams, which “will comprise a range of staff such as GPs, pharmacists, district nurses, community geriatricians, dementia workers and AHPS such as physiotherapists and podiatrists/chiropodists, joined by social care and the voluntary sector.” (LTP p14).

And not just an enabler of integration.  The GP Partnership Review wants more.  It says, “Multi-professional community health teams should be based in Primary Care Networks and work under the clinical and service direction of the Primary Care Network.  They could remain employed by their existing employer while being more closely partnered with, and embedded in, practices day to day.  This should include creating a single team using a common health record, sharing the same caseload, and removing the need for referrals.  Wherever possible, the community teams should also be co-located with the constituent practices of the network.” (Partnership Review 4.46 p30).

The future role of Primary Care Networks does not stop there.  They are the vehicle for online consultations: digital-first primary care is to become a new option for every patient, and to enable this the NHS, “will create a new framework for digital suppliers to offer their platforms to Primary Care Networks on standard NHS terms” (LTP p26).  The GP Partnership Review recommends an even stronger role in relation to access, “Primary Care Networks should be enabled to determine how best to address the balance between urgent and routine appointments during extended opening hours and weekends…NHS England should consider how existing funding for extended access and opening could be allocated through Primary Care Networks as they mature, to enable local decision making on managing demand appropriately” (Partnership Review p32).

They will provide around the clock cover for care homes, “Primary Care Networks will also work with emergency services to provide emergency support (to care homes) including where advice or support is needed out of hours” (LTP p16)

They should be training hubs.  Dr Nigel Watson in his review recommends, “every Primary Care Network should be in partnership with, or become, a Training Hub, ensuring the place-based delivery of education and training in primary care for GPs and other staff working in general practice and staff aligned with the Primary Care Network” (Partnership Review 4.51 p31).

They are to be the new voice of general practice.  “Every Integrated Care System will have… full engagement with primary care, including through a named accountable Clinical Director of each Primary Care Network” (LTP p30).

They will be responsible for health outcomes.  “Primary Care Networks will from 2020/21 assess their local population by risk of unwarranted health outcomes and, working with local community services, make support available to people where it is most needed” (LTP p17).  They will also be encouraged to reduce expenditure.  “We will also offer Primary Care Networks a new “shared savings” scheme so that they can benefit from actions to reduce avoidable A&E attendances, admissions and delayed discharge, streamlining patient pathways to reduce avoidable outpatient visits and over-medication through pharmacist review” (LTP p15).

How is the move to Primary Care Networks going to happen?  Well I suspect we will find out more when the new GP contract is finalised.  For now, the LTP says, “As part of a set of multi-year contract changes individual practices in a local area will enter into a network contract, as an extension to their current contract, and have a designated single fund through which all network resources will flow.  Most CCGs have local contracts for enhanced services and these will normally be added to the network contract” (LTP p14).

In 2019/20 CCGs are required, “to commit a recurrent £1.50/head recurrently to developing and monitoring Primary Care Networks so that the target of 100% coverage is achieved as soon as it is possible and by 30 June 2019 at the latest.  This investment should be planned for recurrently and needs to be provided in cash rather than in kind” (19/20 Planning Guidance p17).

It remains to be seen if that sets a “running cost” of £45-75K per network (assuming 30-50,000 population), or whether it is a starter fund with more to be added later.  One place we might find out is in the primary care strategy that every ICS or STP must have in place by 1 April 2019.  This strategy is to set out, “how they will ensure the sustainability and transformation of primary care and general practice as part of their overarching strategy to improve population health… This must include specific details of their: local investment in transformation with the local priorities identified for support; Primary Care Network development plan; and local workforce plan” (19/20 Planning Guidance p17).

The ambition for fledgling Primary Care Networks, that in some places do not even exist yet, is breath-taking.  They are clearly a crucial building block in the design of the new system for the NHS.  Whether they can live up to the expectations remains to be seen, but they represent a huge opportunity for general practice.  Like them or love them, because even funding is being channelled through them, they are a trend that will be almost impossible for general practice to ignore.

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