What the 2023/24 Operating Guidance Means for General Practice

Every year the powers that be produce “operating guidance” for the NHS for the forthcoming year. It is published at around Christmas time (happy Christmas…) so that NHS organisations and Integrated Care System (ICS) partners can build the guidance into their plans for the forthcoming year.  True to form, this year the guidance was published on 23rd December.  What implications does it have for general practice?

General practice features right from the outset.  The immediate priority for the NHS is to “recover our core services and productivity” and along with ambulance, A&E and elective waits the document prioritises “make it easier for people to access primary care services, particularly general practice” (p3).  No surprise that it is GP access that takes centre stage.

There are three specific general practice targets (p7):

  • Make it easier for people to contact a GP practice, including by supporting general practice to ensure that everyone who needs an appointment with their GP practice gets one within two weeks and those who contact their practice urgently are assessed the same or next day according to clinical need
  • Continue on the trajectory to deliver 50 million more appointments in general practice by the end of March 2024
  • Continue to recruit 26,000 Additional Roles Reimbursement Scheme (ARRS) roles by the end of March 2024

The guidance further notes that an ominously titled “general practice access recovery plan” is being produced and will need to be implemented when published.  It certainly feels like this document will contain more of the actual detail of what systems are expected to impose on practices next year.

There is an annex that, “sets out the key evidence based actions that will help deliver the objectives set out above and the resources being made available to support this” (p8).  I looked forward to turning the page and finding out what these were, but was somewhat deflated to discover that for general practice these are to, “ensure people can more easily contact their GP practice (by phone, NHS App, NHS111 or online)” and “transfer lower acuity care away from both general practice and NHS 111 by increasing pharmacy participation in the Community Pharmacist Consultation Service”.

Disappointing, but not surprising.  Things don’t improve when it comes to the money.  Essentially there is no new money.  Instead, there is an overall 2.2% efficiency target.  Systems are expected to pay acute providers payment for activity performed (no block contracts), and every ICS has to come up with a balanced plan.  For general practice we are told funding has already been agreed in the existing 5 year deal (so don’t expect any more), and if local systems have to stick with payment by results there is very little possibility of any new local investment into primary care.

The challenge when it comes to general practice is that the Operating Framework is always published before the GP contract has been finalised.  In the only nod to Fuller (the Health and Social Care Committee Inquiry report is ignored completely) the document states, “Once the 2023/24 contract negotiations have concluded, we will also publish the themes we are looking to engage with the profession on that could take a significant step towards making general practice more attractive and sustainable and able to deliver the vision outlined in the Fuller Stocktake, including continuity of care for those who need it. The output from this engagement will then inform the negotiations for the 2024/25 contract.” (p10).

This leaves us basically where we thought we were, i.e. that the NHS has no intention of doing anything other than imposing year 5 of the 2019 deal for 23/24, and anything new will have to wait for the next contract that will start in 2024.

All of this is hugely depressing given the challenges the service is experiencing.  Any hopes that the Health and Social Care Select Committee Report would mark a shift of emphasis from access towards continuity have been firmly dashed.  Even the mention of continuity of care feels like it has been done as a concession to the profession, as a subtext to the “real” NHS agenda of GP access.

We will wait and see what (if anything) comes out of the contract negotiations, and what horrors await in the ‘access recovery plan’, but all signs are already pointing to a very difficult 2023 for general practice.

PCN Plus Live Event!

Despite how difficult and challenging it is to lead a PCN there are very events that are directly and uniquely for PCN Clinical Directors and leaders, but I am delighted to say that we are putting on just such an event in the New Year – and you can attend for free!

Let me take a step back to explain the context for this event.  A year ago I got together with three amazing colleagues: Dr Hussain Gandhi, PCN CD and co-presenter of the eGPlearning podblast and all round advocate for general practice and in particular technology in general practice; Dr Andy Foster, former PCN CD and also co-presenter of the eGPlearning podblast; and Tara Humphrey, PCN management expert and presenter of the Business of Healthcare podcast.

Our combined experience of both directly leading and supporting PCNs led us to the realisation that there is very little available for those leading PCNs by means of learning and guidance, and that we were best placed to put that right.  We came up with a brand new course specifically designed for PCN leaders, and PCN Plus was born.

We launched the PCN Plus programme back in April this year with just under 30 PCN leaders.  The group have met every month since then, and we have covered a whole range of topics including how to establish a vision for what you want your PCN to achieve, how to engage your practices effectively and deal with any conflict that comes up, how to make the most of the ARRS roles, and how to manage your PCN operations and finances effectively.

It has been great working with such a dedicated group of PCN leaders who have been so keen to find out more about how they can be more effective in their leadership role, and not only learn from us as a group of facilitators but also learn from each other and share their own experiences to the benefit of everyone else.

But as we reach the end of the course there was one thing we all felt was missing – actually meeting up in person!  It is fantastic being able to meet online and there is a great convenience to it, but there is something special about meeting up in person, even more special now we do it so infrequently.  So we agreed that we will hold an event where everyone who attended the course can come in person, and all finally meet with each other and with the four of us who run the course.

The great news is that if you are leading a PCN you too can attend this event!  As well as learning from the experiences of those who have been on the course so far, we will be focussing specifically on the future of PCNs, on what PCNs can do to be effective within the new Integrated Care System, on what is next for PCN CDs and how can PCN leaders prepare for the challenges ahead.

The event is totally free, but places are extremely limited (there are only 40 available in total) and will be allocated on a first come first served basis.  The event will take place on Wednesday 1st March in Nottingham and runs from 1pm to 4.45pm with lunch (also free!) available from 12.30.  You can reserve your place here – I look forward to seeing you there!

The PCN Manager

PCN managers can be annoying.  As if the practice does not already have enough to do, without the PCN manager constantly ringing up or emailing and asking where the practice is up to with this or making sure the practice does the other by the end of the day.  So where does the real value of a PCN manager lie?

Of course the question is really whether it is the PCN itself that is annoying rather than the PCN manager per se.  Is it really the PCN manager’s fault that the IIF has 1,153(!) points available?  Someone has to monitor it.  And if the PCN agrees to a project or way of working, someone has to be in contact with the practices to make sure that everything that is needed is getting done.

It does, however, beg the question of what we really want from our PCN managers.  Is the job of the PCN manager to be the administrator constantly badgering practices to make sure they are doing what they said they would do?  Or if a practice says it is going to do something is it their own responsibility to make sure it is done, and should the focus of the PCN manager lie elsewhere?

The scale and opportunity of PCNs means that they are now at the point where the PCN manager needs to be something more than glorified admin.  They need to be the ones providing strategic leadership support to the Clinical Director and the PCN.

What does that actually mean?  It means that the role of the manager should be supporting the PCN to ensure that it has a clear vision, and that it has a plan in place to deliver that vision.  It means building relationships within and outside of the PCN to enable that plan to be delivered.  It means finding and securing new opportunities for funding and support to help move the PCN forward.

In too many PCNs all of this responsibility falls on the PCN Clinical Director, who has a myriad of PCN things to attend to in very few sessions each week.  Strategy, strategic planning, relationship building and external opportunities are often the first things to go when there are operational and staff issues that need sorting.

The PCN manager is the key.  They are the ones with the capacity to keep the focus on the important as well as ensuring the urgent is dealt with.  The ability of the PCN to establish and maintain its strategic direction is in a large part down to the PCN manager.  The Clinical Director needs their PCN manager to be working with them to keep the PCN on track.

The problem is that many places do not recognise that this is what is needed of the PCN manager.  Instead they actively seek someone to monitor the IIF targets and PCN DES delivery.  They look for someone junior who can “do the doing”, and do not value the strategic and relationship building skills that are actually the ones that have become the most important.

Equally, many PCNs are not prepared to pay for these skills. The reality is that a manager with these skills will be more senior and have more experience.  They may even earn more than the practice managers (which can be a problem in itself).

PCNs are at a critical point.  The resources and opportunity of PCNs have become really significant, but so have the operational and delivery requirements.  One of the keys to making sure that PCNs add value rather than becoming a drain on resources is finding the right PCN manager with the right skills to ensure the full potential of the PCN is realised.

Allies or Neighbours? Practice relationships within a PCN

One of the key questions facing all practices is how much effort they should expend in collaborative working through their PCN, and how much they should strive to retain their independence and own way of doing things.  But the choice between the two is not as binary as it at first appears.

This Harvard Business Review article maintains that all work relationships fall into one of five categories:

  1. Collaboration (allies) – Merging self-interests with the interests of others
  2. Cooperation (friends) – Maintaining self-interests while also advancing joint interests
  3. Maximum possible independence (neighbours) – acting to neutralise the impact of others on self-interests
  4. Competition (rivals) – working to deter another in order to protect or advance self-interests
  5. Conflict (enemies) – trying to defeat or deny another’s interest

There are some important distinctions between these relationships.  Collaboration involves parties investing in the relationships to help each other.  The benefits of these relationships are the greatest for GP practices, because it means the maximum value can be derived from shared assets, such as ARRS staff and back office teams.  It means practices can potentially realise benefits beyond those that come simply from accessing PCN resources.  The drawback is that these relationships are hard to disengage from should interests change.

Cooperation is a step down from collaboration, where practices choose to work together on specific issues where interests (e.g. availability of PCN funding) align, but simply not to compete where they don’t.  This limits any potential benefits of joint working to those that come from (in our case) PCNs but nothing more.  Should PCNs end then there will still be things that need to be unravelled, but nothing too problematic.

Neighbours is where what practices are actually trying to do is maintain the maximum possible independence.  Practices deliberately reduce their reliance on others as much as they can.  This is where practices want control of their own ARRS staff, and don’t want them grouped into functioning PCN teams.  It limits the benefits that can be derived from PCN resources, but maintains practice independence.

It seems to me that in the vast majority of places now the challenges facing general practice have reached the point where practices no longer feel in competition or even in conflict with each other.  Maybe we sometimes still see it when APMS providers arrive on the patch, but other than that practices generally recognise that practices are in this together, and there is little value in making things even harder by fighting with each other.

The problem many PCNs face is that different practices within the PCN are at different places on this spectrum.  While some may be up for full collaboration, others are striving to maintain their independence.  It is very difficult for a PCN to be effective when what some of the practices are doing is rebuffing any attempts at cooperation, let alone collaboration.

What is needed is to try and get all the practices to agree on the same approach.

The critical point to understand here is that the independence question for GP practices is inextricably linked to the question of sustainability.  If a practice is not sustainable, ultimately it will lose its independence, at the point at which it is either forced to close or is taken over by another provider.  The best chance a practice has of being sustainable into the medium term is by collaborating with other practices, and making the most of the scarce resources that are available to practices.

While it feels counter-intuitive for practices, not to mention risky, the best way to maintain their independence is through collaboration.  For those leading PCNs and joint working initiatives across practices the starting point has to be building a shared understanding this is true, along with the trust needed to mitigate the risk.  How will the practice survive for the next 5 years? How will it navigate the challenges we know are coming down the line, on top of the rising demand and falling GP workforce?  How will it be able to maintain its independence within this context?  What role can the PCN and collaboration play in answering these questions?

Building a shared understanding that collaborative working is the key to maintaining individual practice independence, rather than a fast-track to losing it, is the starting point for successful PCN working.

What is General Practice Trying to Achieve?

For general practice there have been some important documents written this year.  The three that particularly stand out for me are: The Fuller Review; the Future of General Practice (Health and Social Care Committee (HSCC) Inquiry Report); and Side Effects by David Haslam.

I have written about the Fuller Review and the HSCC report, and had the good fortune to be able to interview David Haslam about his book for the General Practice podcast.

While Side Effects is about the system as a whole, it is extremely useful for general practice as it seeks to better articulate its role as a provider within Integrated Care Systems.  David Haslam’s key question for the health system as a whole is what is the healthcare system really trying to achieve?  This, he claims, is a question that most of those responsible for healthcare systems are unable to answer.  Infinite demand and limited resources means systems cannot be universal, high quality and comprehensive, so what is the goal of the system?

We could apply this question to general practice.  Are we really clear as to what general practice is trying to achieve?  Are those leading general practice able to articulate clearly the purpose and role of general practice?

I remember even in my role as a CCG Accountable Officer that I was not crystal clear on the role of general practice in the system, and not fully able to articulate it effectively to acute trust Chief Executives and other system leaders.

It isn’t just me.  Ben Allen, a  Sheffield GP and Clinical Director, recently posted on Twitter,

The Fuller Review seems to distil the aim of general practice as to provide rapid access to care, to provide continuity of care for those who need it, and to play a role in prevention and tackling health inequalities (in partnership with others).

Is this right?  Is this what general practice is there to achieve?

The HSCC Report again is not explicit, but does use this quote, “[T]here are two characteristics of general practice which distinguish the GP from every other professional: first, access and, secondly, continuity of care. That is all there is and everything else supports that.” (p19).  The report broadly states that access has been over-prioritised over continuity of care and that this balance needs to be redressed.

So is the HSCC report right?  Is the role of general practice to provide access and continuity of care, and is the challenge to get the balance between the two right?

David Haslam did not explicitly address the question as to the role of general practice, but he is clear that the challenge for general practice is that much of what it does is not glamorous enough for politicians and the system.  The system does not value the heart attacks and strokes that general practice prevents, because it is not as glamorous as the service that treats a patient who has had a heart attack or stroke.  Even the patient whose heart attack or stroke has prevented does not know that general practice did this!

What he does say is that by investing in primary care health inequalities are reduced and health outcomes are improved.  Is this what general practice is trying to achieve?  And if it is, are we clear exactly how this happens?

Even now I am not sure I can fully articulate the answer myself.  However, the assumptions in the recent publications feel insufficient and inadequate to me.  I am sure that general practice as a profession is not articulating its purpose and role clearly enough.  I don’t even believe there is a shared clarity within the service itself on where the true value of general practice lies.

In the vacuum, the system and politicians just work with their own assumptions.  Acute trust leaders believe many of the patients in A&E are there “because they couldn’t get to see a GP”.  The assumption is that the prevention work of general practice is linear, that general practice stops the need for further care directly and only as a result of its accessibility.  Politicians believe that the aim of general practice is simply to be available when patients want it – hence the obsession with access.

We can´t let these misconceptions continue.  There is a pressing need for general practice, both at a local and national level, to be able to articulate the role of general practice in the system and what it is trying to achieve.  The advent of Integrated Care Systems means it is more important than ever that general practice is clear on the value it brings to the system and exactly how this is achieved.

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