Pack or pride – how should PCNs operate?

The strength of the pack is the wolf, and the strength of the wolf is the pack.” Rudyard Kipling

There is a nervousness amongst GP practices in the intertwining of their fates with those of other practices through PCNs.  The move to robust PCN network agreements can be about protecting the higher performing practices from being ‘dragged’ down by those who are not doing so well.

Equally, as GP practices choose the PCN they are to be part of, there is a tendency for competitiveness between PCNs to emerge.  Instinctively many GPs and practices want “their” PCN to be more successful than those around it, thus justifying the choice of the practice to join it in the first place.

Anyone working in general practice at present understands the pressure that the sector as a whole is under.  When faced with such an existential challenge, there is real value in working together to meet the challenges rather than shifting to a ‘survival of the fittest’ type attitude.

This is perfectly illustrated when considering the respective plight of lions and wolves.  It is estimated there are 20-30,000 lions left in Africa.  50 years ago there were 450,000 lions, a decline of more than 95%.  While historically their numbers had grown, the emergence of man as a predator of lions is the major factor behind their decline.

However, what is astonishing is that the majority of lions are still killed by other lions.  In some prides 80% of the cubs don’t survive.  Either they are killed by other males, or they don’t get enough to eat (they typically eat last in the hierarchy of the pride).  Lions evolved without a predator with an instinct to dominate the savanna from each other, not to share it.

The similar emergence of man as a predator of wolves resulted in the number of wolves declining by about a third.  However, their population is now relatively stable at about 300,000.  Wolves care for each other as individuals.  They form friendships and nurture their own sick and injured.  Pack structure enables communication, the education of the young, and the transfer of knowledge across generations.  The older wolves, as more experienced hunters, share hunting strategies and techniques with younger wolves, passing down knowledge from one generation to the next.

While lions collectively struggle because of their individual desire for dominance, wolves succeed because they cooperate and support each other.

The lessons for newly formed PCNs are clear.  Do we build PCN governance structures to ensure the most successful practices aren’t negatively affected by the practices that are not performing as well, or is the aim to support all practices regardless of their starting point, and to help those most in need to improve?  Do we share information, ideas, resources, expertise with other PCNs, or do we keep it to ourselves and leave other PCNS to work it out for themselves?  Do we collaborate with other PCNs to create a strong voice for general practice, or do we let inter-practice and inter-PCN disputes weaken our collective stance, as we argue against each other in public so that others can simply ignore the general practice position?

We should judge PCNs not on how they are performing relative to other PCNs, with metrics devised by the system, but on how well they are supporting their member practices, and the extent to which they are enabling general practice to thrive.  The more both practices within a PCN work collaboratively together, and PCNs work collaboratively together with each other, the more general practice will thrive.  It may even be we get to a place where “the strength of the PCN is the practice, and the strength of the practice is the PCN”!

What is your Primary Care Network’s Purpose?

I was sitting in a nascent PCN’s meeting recently, and watching the practices grapple with the challenges of forming a new network, and at the same time thinking of the quite common advice for PCNs to establish a common purpose.  Sitting there, I imagined saying to the practices that what they needed to do was spend time identifying and agreeing a common purpose, and equally visualised my rather speedy subsequent removal from the room.

I understand that forward thinking practices can get to the place of considering what the purpose is of their shared network.  But for most practices the current challenges are agreeing who will be in the network, who will be the leader, how they will make decisions, who will hold the money, and how they will deliver extended hours.  There is no time (or patience) for esoteric questions about purpose, when there is so much that needs to be done in the little time they have together.

Does that therefore mean that those PCNs who have not explicitly addressed the question do not have a purpose?  Or is the (unspoken) purpose enabling practices to do what they need to do to fulfil the contract, and receive the funding and resources to which they are entitled?  If there is no purpose at all, you could argue practices would have rejected the Network Contract DES.

Framed more positively, is, then, the (unspoken) purpose of PCNs to increase investment in, and the sustainability, of general practice?  Is it to reverse historic underinvestment and enable general practice to emerge from its current crisis?  Are PCNs in fact a “lifeboat” (as it was termed at a recent Nuffield Trust event) for general practice?

I co-authored a book entitled the Future of General Practice, in which we explored what practices who had emerged from the current crisis had done.  Broadly speaking they have introduced new roles, found ways of working at scale, and began to form partnerships with other providers in the wider system – all elements of the new PCNs.  Like them or loathe them, there is no doubt PCNs represent an opportunity for general practice to create a more sustainable future for itself.

Is it ok for the purpose of PCNs to be first and foremost about investment in and the sustainability of general practice?  As we discussed last week, the system wants PCNs to be about the integration of general practice with the wider system.  And can anything in the NHS be about anything other than improving outcomes for patients?

I would argue that if the system partners with a general practice that is essentially broken, the benefits will be limited.  And if supporting general practice is the way to improve outcomes for patients, then it is perfectly reasonable for that to be its primary goal.  Where general practice is in crisis, the purpose of PCNs needs to be to support them out of it.  Integration with the wider system, and improved outcomes for patients, will be happy bi-products of this primary purpose being fulfilled.

The challenge for PCN leaders is to be clear on the purpose of their PCN.  While the discussion might not explicitly have been had, GP leaders will know why their colleagues are turning up and what their expectations are.  I think there is actually real value in these leaders making the implicit explicit, and using this positive articulation of exactly what it is practices are doing together to give energy to the PCN from member practices.  Ultimately, practices, the wider system and patients will all benefit from this.

What are PCNs: joint working between practices, or something more?

There is an almost palpable dissonance that sits between the Primary Care Networks (PCNs) as constituted in the PCN DES, and how they are perceived in the minds of CCG leaders and those responsible for developing integrated care systems.

On the one hand the GP contract portrays the DES as a framework for practices to work together and to secure investment into general practice over the coming years.  The system, meanwhile, seems to think of PCNs as the building blocks of the local integrated care system, with a membership and remit expanding far beyond core general practice.

So who is right? Are PCNs a contractual construct of joint working between practices, operating solely within the framework of the national GP contract, or are they something more, owned more widely across the system and with an accountability beyond the terms of the GP contract?

This question is one general practice would do well to take time to consider, because the implications are far reaching.

A good place to start is the Long Term Plan for the NHS, published just before the new GP contract.  In chapter 1 of this document, which sets the direction for the NHS for the next 5 years, it sets out five major changes to the NHS service model, the very first of which is “we will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community services” (Long Term Plan p12).

How will this be achieved?  Through PCNs. Through the investment of £4.5bn in “expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices… Most CCGs have local contracts for enhanced services and these will normally be added to the network contract… The result will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care” (Long Term Plan 1.9-1.10 pp 14-15).

There are some important points to note here.  First is that, in case anyone is in any doubt, the primary purpose of PCNs is the integration of primary care with the rest of the system.  The contract has been used as a necessary mechanism for setting them up.  How else can you integrate independent contractors?

Second, is that the promised £4.5bn in the Long Term Plan is considerably higher than the £1.8bn promised in the GP contract to support the formation of PCNs.  This is because the majority of investment in PCNs will not be through the core GP contract.  The funding that comes from other sources (which, by the way, represents a huge opportunity for general practice) will, inevitably, bring with it an accountability outside of the core contract, and into the wider system.

The other place to look is the PCN Network Contract DES, which notes the key features of the DES are set out in the Long Term Plan (and so references the points above without explicitly stating them).  It says the DES is subject to annual review and development, and that the focus in 2019/20 is “to support the establishment of PCNs and the recruitment of the new workforce, with the bulk of the service requirements coming in from April 2020 onwards” (Network Contact DES Specification p5).

So this year (the easy one) is about practices working together, and essentially getting ready for what is to come from 2020 onwards.  That is when the shift will accelerate away from core general practice.  The Network Contract DES guidance states, “PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care. To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.” (p16-17).

One of the service specifications coming in 2020/21 is the innocuous-sounding anticipatory care, “The Anticipatory Care Service will need to be delivered by a fully integrated primary and community health team. To support this, from July 2019 community providers are being asked to configure their teams on PCN footprints. The requirements will be developed across the country by ICSs, and commissioned by CCGs from their PCNs. NHS England will develop the national requirements for the essential contribution required under the Network Contract DES.” (p18).  Within one of seven DES service specifications the NHS has effectively announced the full integration of primary and community care!

Back to the original question – are PCNs about contractual joint working between practices, or about integrating all services within a local community?  While today the answer is largely the former, it is clear from 2020 onwards the answer is very much the latter.  There is no real dissonance (other than between the expectations of pace setting system leaders and the reality of where their local networks are).  PCNs are on a journey.  The start of this journey (and where we are today) is joint working between practices, but very quickly this will evolve into joint working between that group of practices and the rest of the local health and social care economy.  This is the DES practices have signed up to, and these are the changes that are on their way.

Primary Care Networks: A Roadmap until the end of June

While many have sat back and breathed a collective sigh of relief that the 15th May deadline was met for the submission of the initial PCN returns, that was unfortunately only the start of the journey.  Some pretty formidable challenges lie ahead.

I am sure some PCNs have a clear plan and are meticulously ticking off actions and making sure everything is sorted as they get ready for the 1st July, when PCNs formally begin.  This is less for those PCNs, and more for the time poor and those who have that feeling there is something they should be doing but they are not sure exactly what! It also doesn’t cover everything you could be doing (if that’s what you need do watch out for Clare Allcock’s wonderful advice on how to accelerate collaborative working in next week’s podcast).  Rather this is designed to help you meet the minimum requirements.

Essentially, each PCN has to complete three key actions by 30th June:

  • Agree how extended hours will be provided at a rate of 30 additional minutes per 1,000 registered patients to all registered patients within the PCN.
  • Ensure appropriate data sharing agreements and, if required, data processing arrangements are in place, using the national template, to support the delivery of extended hours.
  • Ensure the network agreement is completed (including all seven schedules), and signed.

For the provision of extended hours, each PCN will need to know:

  • Does each member practice wish to undertake the delivery of extended hours for their practice population?
  • If any practice does not, is there another practice willing to take the delivery of these hours on?
  • If not, is there a third party who can deliver the services on behalf of the practices?

It is easiest if each practice does their own extended hours, next easiest if there is some sort of buddy arrangement between practices so that they can cover each other, and least easiest if you have to create some new model of joint working across practices.  That is not to say one model is better than the others, only which is easier in terms of the amount of work each will require in the month until the next submission is due.

Now you may be lucky and already have data sharing agreements in place between your practices.  If you don’t, then there is the promise from NHS England of a national template.  Unfortunately, the PCN frequently asked questions states that this is not yet available as it has to be agreed with the GPC.  Watch out for its publication, as you are not going to have long to turn it round and get it agreed by your member practices.

As for completing the network agreement, remember the starting point for each PCN is the mandatory network agreement (here).  This mandatory agreement cannot be altered.  However, there are 7 schedules where additional clauses can be added.  The template for completing the schedules can be accessed here.

I am not a lawyer, so this is not legal advice, but if you had to prioritise you could go with the suggested wording of the national agreement and not worry too much about schedule 2 (essentially this schedule is where you can make changes/additions to some of the mandatory network agreement), and for schedule 6 you could go with the suggested list of insolvency events (it is essentially a list of different events of insolvency that would enable members to take action under the clauses).  The difficult bits you would then have to sort out are:

  • The rest of schedule 1 (you have already done some of it) where you have to say how the meetings will take place, what is quorate, how you will make decisions etc etc
  • Schedule 3 where you outline everyone’s responsibilities in delivering extended hours
  • Schedule 4 where you have to outline all the network’s financial arrangements (how much money each practice is getting and who is going to pay it)
  • Schedule 5 where you set out the arrangements in the PCN for engaging or employing staff, including arrangements for employment liabilities
  • And schedule 7, which is essentially how you will work with any other organisation (e.g. a federation). Top tip here is get them to draft it for you, and then change their version, rather than starting with a blank piece of paper.

I don’t know how many meetings you are realistically going to have with your practices between now and the end of June, but if it isn’t many you may want to find someone to draft a starter for 10 for each of these schedules.  If you can agree 90% of them remotely, then you can use any valuable meeting time to focus on the hopefully small number of areas that are left.

And once you have done all that, you are probably going to need to get a lawyer to look over the final agreement with all its appendices before you can persuade your practices to sign it.   Remember the submission of the network agreement is due by 30th June which (inevitably) is a Sunday, which means the 28th June, which means there is only one month to go to get everything done.  No pressure!

What would be really helpful would be sharing across PCNs of good ideas for improving the agreement between practices, strong additions to the network agreement, and good wording for the schedules.  Anything we find along the way we will definitely pass on.

I hope that is useful.  If you have any advice for over-stretched incoming PCN leaders that I have missed please do get in touch to share.  Good luck all!

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