Has the employment liability question been answered?

The Updated GP Contract states that there are now three measures in position to reduce the risks associated with employment liabilities. This has generally been well accepted and people have moved onto looking at other questions.

Unfortunately, a careful look at these measures reveals very little actual change between the new and the original position.  The three measures represent an option that already existed (measure 1), a partial statement of the law as it has always been (measure 3), and a vague assurance about the future of funding which does not directly give assurances about employment (measure 2).

It is important not to create and continue periods of negativity, and as someone who is generally supportive of the principles underpinning the PCN project it is difficult to appear too critical. However, this has to be balanced by a true understanding of the risks.

If the wrong decisions are taken now, or if over reliance is placed on vague assurances, practices may find their original fears come true.  This in turn creates a further disconnect in the relationship of trust between the practices and the commissioners.

From a practical perspective, I was speaking with a GP partner earlier in the week who had committed to taking on the employment responsibility of all the new staff due to the assurances of the measures. I corrected his view, and this has resulted in a redesign of appropriately shared liabilities across the PCN members.

I have written a longer piece relating to the measures as they have currently been outlined for specific concerns and recommendations. The following is a quick summary of the measures within the updated GP contract:

  • Measure 1 – Using third party contractors

These can be structured in different ways and the extent to which these are provided will vary the degree of protection. They need to be financially viable and should offer the service that you are after. VAT remains a risk if it is not structured correctly. Good contracts are essential in forming these documents.

 

  • Measure 2 – Funding secured within the core contract

This is a good change, but ensure your plans have sufficient security for the employing practices should the money be split between other practices. You may find that you employ an individual but the money is with multiple other practices with no mechanism to claim it. A cross-indemnity arrangement may resolve this risk.

 

  • Measure 3 – Reliance on the future application of TUPE

TUPE has complex rules relating to when it does and does not apply. Most importantly it does not apply where services cannot be clearly defined and employees directly linked with those services. How each specification requirement is structured, and how each additional role is utilised across the PCN, will significantly alter the risk. In many cases it is hard to see how this protection will apply where the team members are integrated into core general practice delivery.

In practice it is important to note that these are the same risks faced by the providers of all time-limited contracts. APMS and AQP providers have had the same issues and it could be argued they have damaged the ability of many of these providers to retain staff and have partially resulted in the higher rates than GMS contracts.

The only definitive solution is a legally binding indemnity from the commissioners relating to redundancies directly resulting from a change of policy. This remains unlikely, and even if it could happen it is some time away.

Practices and PCNs should therefore ensure that this is a defined risk with a suitable management plan based on categorisation of staff. Certain steps can reduce the risk, including the following:

  • Ensure that contracts with third parties are viable in the long-term and that all liabilities are covered;
  • Develop an indemnity between the practices to ensure the funds are appropriately managed, to reduce the risk of funds being split between multiple practices and creating a shortfall for the actual named employer;
  • Where possible, directly link staffing to service delivery. This may reduce flexibility but it improves the chance that TUPE will apply.

Finally, if in doubt seek support when making plans and ensure that you fully understand the risks!

 

Robert McCartney, Managing Director, McCartney Healthcare Associates Ltd.  You can contact Robert by email rm@mccartneyhealth.co.uk.

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The PCN Clock is Ticking: Your 3 Month Plan

We now know what is in the GP contract update for next year.  But we are worried that the LMC conference in March might change things.  We don’t know if our practices will sign up again to the PCN DES, and won’t know for sure until the end of May.  So what should we be doing now?

The problem PCNs have, given the challenges posed within the contract for next year, is that they do not have a spare three months.  Meeting the contract requirements is going to take all the time available, and trying to move from a standing start at the end of May is going to make life very difficult for any PCN that postpones taking action.

Where should PCNs start?  It will of course depend on the individual circumstances of each PCN, but a generic plan for the next three months will look something like this:

March

Undertake a workload analysis for 2020/21.  This will include working through the detail of the three PCN specifications, identifying what your “social prescribing service” is going to entail, working through the actions required to achieve the 8 indicators in the Investment and Impact Fund, as well as any actions needed to continue or develop any local priorities or initiatives.

Get the information you need from your CCG.  This will include the list of care homes and number of care home beds in your PCN, the exact amount of your Additional Role Reimbursement Scheme (ARRS) funding for next year, and any additional support the CCG will provide.

Put management support in place.  You may have already done this, but if you haven’t, then now is the time, because the demands on PCNs next year are much more onerous than this year.  Don’t wait until several months in when the PCN CD is on the verge of resignation/breakdown to make this happen.  Use the PCN development money, the £1.50 running costs, or grab any support the PCN is offering – access management support however you can.

Establish your end of 2019/20 financial plan.  By now you will have a good idea of how much money the PCN has spent, is going to spend, and what will be left over.  You need to decide how this funding is either going to be used or distributed to the practices.  You need to do this in March so that if you do want to do anything with the funding it is not too late to make it happen.

April

Define the roles you want.  Once you have completed the workload analysis the PCN will need to decide how to use the ARRS funding to deliver the workload.  PCNs have to formally submit their “workforce intentions” by the end of June, but, frankly, this is too late.

Create a local recruitment campaign.  The contract update indicates that CCG HR resources will be available to PCNs to support them with recruitment into these new roles.  It would seem wise to take up this offer to attract the highest possible calibre of candidates locally.

Establish a financial plan for 2020/21.  As the total income and expenditure will be higher for the year ahead, it is even more important that each PCN establishes not just a plan to deliver the workload and a workforce plan, but also a financial plan to run alongside.

Finalise the 2019/20 accounts.  I can’t stress enough the importance of PCNs sorting out their end of year accounts as early as possible.  If there are any tax implications for the member practices, then they need to be informed of these as early as possible.

May

Push on recruitment.  Recruitment is notoriously slow, and so PCNs will need to make sure the process is being actively managed to ensure the staff they need to enable delivery are in post as quickly as possible.

Prepare for the incoming roles.  Making the new roles a success involves more than simply getting people in post.  PCNs will need a clear plan of how each role is going to be managed, supervised and supported, as well as how they will operate and what they will do.  The better the preparation for the new roles, the more likely that they will be a success.

Create a detailed work plan for each workstream.  PCNs will need to build on the workload analysis carried out in March, and hopefully by now be able to use some management resource, to create a detailed work plan for each of the service specifications and each of the areas of work identified for the PCN.

Sign up to the DES.  At the end of May, practices will need to sign up (or not) to the PCN DES.  If PCNs have carried out all the work above, it will be much easier for practices to be able to understand exactly what is involved and how it is going to be achieved when making this decision.

 

This is not an exhaustive list.  For example, you might want a stakeholder plan (how you are going to work with neighbouring organisations to support/enable delivery of the workload), an estates plan (where are these new roles going to be based), or an IT/data sharing plan (how will you deliver services across multiple practices), depending on your local circumstances.  Equally, you may already have some of the components of the plan in place.  The key point is that the next three months are a vital period for PCNs, and it is important PCNs don’t waste the opportunity to build some momentum into the coming year.

Is it time to go “all in” on PCNs?

What is going to happen with Primary Care Networks (PCNs) at the end of the 5 year PCN DES?  Are PCNs going to be a here-today-gone-tomorrow phenomenon, or are they here to stay?  And does it matter?

I think this is a really important question.  It is important because the answer should probably shape how practices approach PCNs, and determine the amount of effort and engagement they put into them.

There are some significant clues in the recently published update to the GP contract.  The update states that the additional roles employed under the PCN DES, “will be treated as part of the core general practice cost base beyond 2023/24” (1.20).  This means £1.13M of additional roles funding (for the “average” PCN) will at that point become part of the core contract.

The Investment and Impact Fund (think QOF for PCNs) will be worth £300M by 2023/24 (£240k per “average” PCN).  This is going to provide population based coverage at a meaningful level within an Integrated Care System in a way that the individual practice QOF does not.  Would it be a huge surprise if future additional investment focussed on the PCN IIF rather than the individual practice QOF?  It would be more of a surprise if it didn’t.

Of the 45 pages containing the details of the updates to the GP contract, virtually half (22 pages) is dedicated to PCNs and PCN initiatives.  The main changes to the GP contract are already now coming through PCNs.  With all the effort and resource that has gone into establishing PCNs and creating them as a platform, it seems highly unlikely that at the end of the 5 years they will be stopped.

More likely is that as the funding for the additional roles shifts into the core general practice contract, so PCNs themselves will shift from being an optional additional service to a core part of the contract.  Despite the nervousness around PCNs that the publication of the draft PCN DES specifications raised earlier this year, the final update reads as though practices and PCNs are already inextricably linked.  And if not now, they certainly will be by 2024.

If you believe this to be true, what does this mean for an individual practice today?  I think the implications are significant.

So far it has been possible to treat PCNs as an optional extra, something a practice can dip in and out of, and leave the work to those prepared to volunteer to take it on.  The implications of the shift signalled in this year’s update are that this level of engagement is no longer going to be enough, because letting PCNs develop in ways that don’t support your practice could jeopardise your practice’s future in the medium term.

Practices are going to have to work to ensure that they are directly receiving the benefit of the new roles and the new sources of funding.  They can’t leave it for others to sort out, and rely solely on the income they receive directly (i.e. not via the PCN).  Over time the PCN will become more established and the ability to shape and influence it will become less for each individual practice.  Practices need to work now to make sure the PCN is working for them and their population.

If I was a partner of a GP practice, my take on this year’s update to the GP contract would be that now is the time to go “all in” on PCNs.  While last year there was probably sense in taking a watching brief to see how PCNs developed, now I think the time for that strategy has come to an end.  The signals are all there that the future of GP funding is going to come through PCNs, and I would want to be right at the forefront of making that work for my practice and my patients.

What to Make of the Updated GP Contract Agreement

I am not sure how many of you will have read by now the “Update to the GP Contract Agreement 2020/21 – 2023/24” released by the BMA and NHS England last week, but having waded through all 86 pages it is hard to take it all in. There are huge implications in particular for PCNs, who will need to digest the contents quickly to be able to move to action.

First things first. It looks like the big problems caused by the draft PCN DES specifications have been addressed. The biggest sticking point was no extra money to deliver the required extra work, followed by the seeming requirement that all of the additional roles would be used to deliver extra work and not support core general practice, with practices expected to chip in 30% of the funding for the privilege. The draft specifications were also seen as over-prescriptive, stifling local innovation and responsiveness.

This update addresses these issues in some surprising ways. The number of specifications needed to be delivered in year has been reduced from 5 to 3. Only structured medication reviews, enhanced health in care homes, and supporting early cancer diagnosis remain, with the other four to follow next year (two were always planned to be implemented from 2021). PCNs are also to “provide access to a social prescribing service in 2020/21, drawing on the workforce funded under the network contract DES” (7.5, p41).

100% reimbursement is to be provided for the new roles, removing the need for a 30% contribution from member practices/the £1.50 per head. This won’t solve the problem of being able to recruit into the roles at the funding levels available, but it tackles the major issue of sourcing the 30%. 6 new roles have also been added to the list that PCNs can use this funding to recruit from: pharmacy technicians; care coordinators; health coaches; dietitians; podiatrists and occupational therapists.

Importantly, assurances are made that the funding for these roles will continue in the core GP contract beyond 2023/24, and that should practices withdraw from the PCN DES the roles would TUPE to whichever provider takes over the delivery, alleviating concerns about future liability costs.

Access to further funding is also provided for PCNs. The level of funding available to source these new roles has been increased. Where it was, for an “average PCN”, £206k in 2020/21 it will now be £344k. An additional (recurrent) £120 per care home bed per year will be directly provided.

PCNs can also access funds through the Investment and Impact Fund (IIF). This looks like it is essentially a QOF for PCNs. It is a points based system, with a number of areas each with indicators allocated a certain number of points. There are upper and lower thresholds beyond which no payment is made, with a sliding scale rewarding performance in between.

The “average PCN” can earn £32,400 in 2020/21 from the IIF (although it has to declare it will use any funds earned for workforce expansion and services in primary care). This will rise to £240,000 per PCN by 2023/24. There are 8 indicators for 2020/2021 for seasonal flu vaccinations, LD health checks, referrals to social prescribing, gastro-protective prescribing (3 indicators), metered dose inhaler prescriptions, and spend on medicines that should be routinely prescribed.

The challenge, then, for the PCN is first of all to identify its overall delivery requirements for next year (delivery against the specifications, delivery of a social prescribing service, delivery against the IIF indicators, and any agreed local delivery).

Then the PCN in relatively short order has to establish the additional roles it will need to enable this delivery. PCNs are required to produce (and submit) their workforce “intentions” by 30th June at the latest, but will most likely need to be actively recruiting well ahead of this. The document encourages, in light of the additional role reimbursement funding, PCNs to use the (existing, recurrent) £1.50 to appoint a full time manager and increase PCN Clinical Director time so that the growing PCN workload can be managed effectively. Sounds sensible.

It does seem that there are sufficient resources available in the updated contract to meet the requirements it makes, while at the same time leaving some freedom for local developments, delivery and innovation. This was always the key for me as to whether the revised proposals would make sense.

There is of course more in the update that I haven’t touched on. There is a renewed focus on increasing the number of doctors, with initiatives including a new two year fellowship programme for all newly qualified GPs and nurses, a new to partnership one off payment of £20,000 to encourage GPs to become partners, and a locum support scheme to encourage consistent locum working with groups of PCNs.

We may have a new government but access inevitably features. This year all practices will be required to participate in an appointments dataset, and then it is about preparation for April 2021, by when there will be a “nationally consistent” offer developed for bringing extended hours and extended access funding together, as well as a core digital service to be offered to all patients.

A new payment mechanism for vaccinations and immunisations is being introduced over the next two years. This year it will become an essential service with new contractual core standards that practices will be expected to meet, and an item of service payment of £10.06 introduced for MMR 1 and 2. In year 2 the item of service payment will be expanded to other areas, and a new QOF domain for routine vaccinations will be introduced, with the existing childhood immunisation DES retired.

There are, as ever, a few adjustments to QOF, but that is the bones of the changes within the updated contract agreement. I am sure it will take time to take it all in (especially getting our heads round the new investment and impact fund!), but from first impressions it seems that PCNs may well survive the turbulence of the last few months and be able to build a platform from which they can start to make a real difference.

It is Not a Race

I am lucky enough to be in a role where I meet lots of Primary Care Networks in different parts of the country.  One of the most common things they tell me is that they know that they are “behind” where everybody else is.

This is interesting for a range of reasons.  Firstly, if everybody is behind everybody else, who is in front?  The influence of social media is such that when we hear a few PCNs report on what they are doing, our immediate reaction is to think we are not doing that so we must be behind, even without knowing anything like the whole story of what is going on in that other PCN.  By and large we tend to share what we are doing well on social media, not what we are struggling with.

Secondly, what does being “behind” actually mean?  How do we determine if a PCN is ahead or behind?  Is it the extent to which they are meeting the DES requirements, meaning the PCN that has a network agreement, a data sharing agreement, a social prescribing link worker and a pharmacist is ahead, and those that don’t are behind?  I am not convinced this is going to be the best indicator of ultimate PCN success, because it is possible to have all those things in place simply with a level of passive compliance from member practices as opposed to any active ownership.

Maybe it is distance along the PCN maturity matrix that is the best measure of progress?  Just in case you haven’t fully internalised the PCN maturity matrix, it identifies five components of a PCN development journey: leadership, planning and partnerships; use of data and population health management; integrating care; managing resources; working in partnership with people and communities.  Now I wrote back in August about the dangers of a nationally prescribed maturity matrix imposing requirements or expectations on a PCN.  Ultimately each PCN should determine its own purpose, and make its own decision as to what its maturity would look like.

Thirdly, is being ahead a good thing?  If we have learnt anything from the DES specifications it is that showing a little bit of caution may actually be wise in the current environment.

As regular readers will know I am a big fan of Professor John Kotter at Harvard and his approach to change management.  He believes assuming people know that change is needed, and focussing instead on strategy and solutions (like PCNs) is what kills most change efforts.  He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change and make PCNs a success.  There is work for PCN leaders to do to get to this point.

So if PCNs are ultimately an exercise in change management, which is what makes them difficult, then moving too quickly into doing things without spending time coalescing around a shared vision is likely to be a recipe for long term failure.  Meeting contractual requirements, or ticking the boxes on the maturity matrix, are a long way from winning the hearts and minds of member practices and local partners.

PCNs are not a race.  There is no prize for being “ahead” (whatever that means).  Taking time at the start to understand what the PCN is for, and what transformation its members want it to deliver, and building trust across the network (however long this takes) is key to making the most of the opportunity that PCNs provide.

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