As PCNs enter year 3 of their existence, they are growing in complexity.  Not only is the number of staff employed by the PCN continuing to increase, the expectations and requirements on PCNs is also going up.  The more the PCN becomes like a business in its own right (as opposed to a shared enhanced service across practices), so the importance of the PCN having a financial plan grows.

To date it has been easy enough to monitor the finances based on the individual funding streams associated with the PCN: the ARRS funding (which has pretty tight rules about how it can be claimed); the PCN CD funding (which generally goes to the PCN CD); the extended hours access payment (which generally goes to the practices who have provided it); and the £120 per bed care home premium (which is generally paid according to the beds managed by each practice).  I have not included the network participation payment as it is paid directly to the practices and by and large stays there.  That only really leaves the core £1.50 per head funding, and the PCN development monies (which are handled differently in different parts of the country) that have required any debate as to their allocation.

It won’t be so simple going forward.  This is for a number of reasons.  The first is that many PCNs have been managing the vaccination service which is highly unlikely to have exactly broken even, and so have to decide how any surplus is to be used.

The second is that the PCN CD money has once again been increased to 1 wte for the April to June period.  This creates a significant sum: a 50,000 population PCN will receive just over £26,700 extra for these three months.  Most PCN CDs do not have the capacity to work full time in the role (because of their clinical and practice commitments) so PCNs have to decide how they will make best use of this funding.

The third is the Investment and Impact Fund (IIF).  Not only will PCNs (eventually) receive payment for achievement against last year’s IIF (up to £21,534 for the average PCN), there is a small in year payment available for this year (£5,400 for mapping appointment slot types to national categories by the end of June), as well as the opportunity to earn £40.5k in total by the year end from the indicators announced.  The total IIF earning opportunity is due to rise to over £120k with the addition of the indicators not yet announced but set to commence in October.

The IIF funding has caveats not contained within the core funding and any funding earned from the vaccination service – “a PCN must commit in writing to the commissioner to reinvest any IIF Achievement Payment into additional workforce, additional primary medical services, and/or other areas of investment in a Core Network Practice” PCN DES 10.6.16.  It is the arrival of the IIF funding that means it suddenly becomes more sensible for PCNs to think about the finances in the round, as opposed to in terms of each individual funding stream.

If a PCN combines its core funding, any surplus generated from the vaccination work, the IIF funding, any unallocated PCN CD funding, plus any development monies it has been able to secure, then it can create a funding pot that it has relatively flexible use over.  There are some requirements governing some of these funding sources, but if a PCN can create an overall expenditure plan (i.e. how it wants to use the money it has), it can generally allocate the expenditure items against the different funding sources to ensure it complies with the rules.

So for example if a PCN is looking to reimburse GP time for clinical supervision of ARRS roles, or employ a PCN project manager, it may be better to allocate at least some of this out of the IIF monies rather than the core funding as it meets the IIF requirements and means the PCN then has total freedom for how it uses the remaining funding.

This financial complexity will continue to increase for PCNs moving forward.  The new PCN specifications likely to be introduced in October will have demands that require some sort of funding.  The IIF is due to be worth nearly a quarter of a million pounds to the average PCN by 23/24.  The commissioning of extended access via PCNs from next year will have its own financial (as well as operational!) challenges.

Now is the time for any PCN that has not created a comprehensive financial plan (as opposed to managing each of the PCN finance streams in isolation) to do so.  It is a good habit to create, and one that will reap significant dividends down the line.

Many PCN CDs describe a sense of uncertainty as to what exactly it is they are supposed to be doing in the role, and are concerned as to whether they are meeting expectations.  Often they are plagued by self-doubt, exacerbated each time they hear of another PCN achieving something that they may not have even thought of.

What makes a good PCN Clinical Director?  What is the role really about, and how do you know if you are being effective?

There are three things to understand about the PCN CD role:

The role is about making change happen.  Ultimately what will separate the successful PCN CDs from others will not be how many meetings they attended, how well they understood the PCN DES or the intricacies of the ARRS, or how many WhatsApp groups they were on.  It will be whether they were able to make change happen within their PCN.

But making change happen is not easy.  People do not like change (even the ones that say they do!).  We all gain comfort from our routines and ways of doing things.  Change means stepping out of these and doing things we are unfamiliar and uncomfortable with.  Naturally, we will all resist change.  Even when the new way of working is better, most of us will be reluctant to make the step away from what we are currently doing.  It is human nature.

The PCN CD role is about making sure the changes that are chosen are the right ones, and that those within the PCN make these changes.  Which leads us to the second thing to understand about the PCN CD role.

The role is primarily about people.  Making change is really about people.  It is about building relationships and trust so that when you ask those people to move in a certain direction, they trust you enough to follow.

This is not easy to achieve.  People within a PCN will not do what the PCN CD says, just because they have the title “Clinical Director”.  They need a reason to leave the comfort of where they currently are and what are they currently doing to move in the direction the PCN CD suggests.  An effective PCN CD is one who can make this happen.

The role is not about being popular.  Inevitably, different people within the PCN will want to do different things and to move in different directions.  The PCN CD ultimately has to make the decisions about what to do and where to go.  To be effective they can’t be seen to be favouring one individual or practice or group over others.  While others can seek support from their peers, no one else within the PCN will experience the same set of challenges that the PCN CD faces.

Those seeking popularity should not take on the role.  Not only is it lonely, but managing conflict is inherent within it.  There is always an individual or practice actively blocking any change that you are seeking to introduce.  Where the opposition is not vocal and overt, the leader’s role is often to seek it out and bring it to the surface so that it can be dealt with.  Constantly dealing with conflict makes sustaining positive relationships challenging, as well as being exhausting.

One of the best ways of dealing with this loneliness is to engage with peers who are in the same situation.  Other PCN CDs and primary care leaders are the best source of support, as they are most likely facing a similar set of challenges.

Dr Rachel Morris, GP and host of the You are Not a Frog podcast that focusses on resilience, has established a Resilient Team Academy.  This is an online membership programme for PCN CDs and busy leaders in healthcare that not only provides a community of like-minded colleagues, but provides coaching, productivity and resilience tools to support you in your role, and will help you as you lead and support your practices and team.

I have teamed up with Rachel and we have created a 6 module online course on how to get people and practices to work together across a PCN.  In the course we provide practical advice on what PCN leaders can do to be effective in the role, and how to avoid the common mistakes that are made such as forgetting it is about people, and taking things personally.

Rachel’s Resilient Team Academy only opens a few times a year for new members.  If you want to join you can do so now, but only until Monday 3^rd May.  If you join using this link you can receive a 15% discount on the joining fee, and receive the online course on joint working across practices for free.  It is risk free, because if you change your mind once you have joined, there is a 90 day no quibble money back guarantee.

An effective PCN Clinical Director is one that can make change happen, and can build the relationships needed to achieve this.  It is one of the most challenging jobs there is right now in general practice, and I would strongly recommend that anyone wanting to make a success of this role makes sure they put the support they need in place.  The resilient team academy is a great place to start!

If I were to ask you this question directly, your knee jerk reaction may be, ‘Of course, why else would I work with them?’.  But for many of us, this question raises some uncomfortable truths.

Yes, I may have ‘competency-based trust’ in my colleagues. I know they are capable of practicing safely, have good clinical knowledge and go above and beyond in the care of patients. I also know they are honest, good upstanding citizens and unlikely to nick my car…

But do I really trust that I can speak up, raise difficult issues with them, give them some feedback about the way they behaved in that meeting, challenge a decision they have made about a patient or disagree with something they have done? AND that our relationship will be totally fine afterwards?

Do I know that they always assume I have a good intention towards them? Do I know they will forgive me if I get it wrong or fail at something – even if I should have known better?

This is a different level of trust – vulnerability-based trust.  It is what makes teams work – or not. It is a key ingredient of psychological safety – essentially a climate in which people, ‘are comfortable expressing and being themselves…in which they are comfortable sharing concerns and mistakes without fear of embarrassment and retribution and…they are confident that they can speak up and won’t be humiliated, ignored or blamed.’ Amy Edmondson, The Fearless Organisation.

Unless we have this sort of trust within our teams, we are effectively trying to drive a high-performance car in first gear. The team won’t even be the sum of its parts, and certainly won’t be able to conflict and disagree well, which will lead to artificial harmony, lack of commitment, accountability and ultimately poor results.

One of the major reasons why PCN Directors and other leaders in healthcare struggle to get projects off the ground is an absence of trust in the team between the individuals from the different practices or organisations.

Teams with high levels of trust and good psychological safety have less medical errors, better outcomes, more engaged staff and better performance, so building trust in your team should be a priority for any PCN Director. The problem is that so often we focus on tasks and processes rather than building relationships and trust. Whilst doing a task together is a good way of beginning to build trust (if you do it right!), neglecting to work on the relationships can have dire consequences and can de-rail the whole thing.

So how do you build trust within your teams?

• Really get to know one another. This doesn’t actually take too long. It is possible to make a deep connection in less than a minute if you ask the right questions. Show genuine interest in the other person (and then remember their answers!). Find some ‘uncommon commonality’ (perhaps you have children at the same school, or you’re both origami enthusiasts) or something about their past that shaped them and affected them deeply. Don’t forget to create times where you can have informal interactions (admittedly much harder online – it can be done but you’ll have to plan it more).
• Model vulnerability. Tell people when you’re worried about something, share where you’ve made mistakes and ask for help. Self-disclosure is a powerful way of building a deep connection with people and it shows you trust them if you’re asking for help.
• Assume good intent from others. Assuming that someone has your best interests at heart and that they are saying that thing because they are genuinely concerned, want to learn from mistakes, make things better and that they care about you too is a powerful mindset and the basis of psychological safety. It will allow teams to address all sorts of things in a non-judgemental, open and curious manner. It will help people speak up, recognise problems and challenges before they happen and save a whole load of hassle and heartache.
• Seek first to understand before giving your opinion. Not only will you build trust but you’ll come across as wise too.

Leading teams in healthcare is ultimately about people, not about process. Focus on building trust within the teams in which you work and you’ll reap the rewards several times over.

For more about how to build trust when working across teams in practices and networks, check out the brand new BONUS spotlight course from Ben Gowland and Rachel Morris  ‘How to work together across practices and networks: 6 mistakes leaders in healthcare make and how to avoid them’ available free to you when you join the Resilient Team Academy – a membership for busy leaders providing monthly Deep Dive Masterclasses, ‘done for you’ team resilience building activities, teaching you how to use the Shapes Toolkit coaching and productivity tools with your teams and giving you a likeminded community of peers. Find out more here.

It might not seem like that long since the GP Forward View (GPFV) was published, but at the end of the March we come to the end of the 5 year GPFV period.  Just as a reminder, the headline of the GPFV was an investment of £2.4bn over those 5 years to demonstrate that the challenges in general practice had been heard and understood, and to provide real financial and practical support to the service.  What did the GPFV achieve, and where has it left general practice now?

There are a number of reflections to make about the GPFV:

5 years is too long a time frame.  In 2019, 3 years into the GPFV, the GPFV was effectively superseded by the new 5 year GP contract and the introduction of Primary Care Networks (PCNs).  When announcing funding uplifts a longer timescale works better because the money sounds more, but the reality is things change too much over that time period for it to remain a firm plan.  No one has really spoken about the GPFV for the last 2 years since the new contract was introduced.

It was really about access. While not immediately obvious, what became clear from the GPFV over time was that the real intention of the document was to deliver the government’s agenda of improved access to primary care.  The only significant recurrent additional funding in the GPFV, on top of the contract awards, was the £500m funding, or £6 per head of population, for additional access.  What then happened was 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 alternative providers – the £6 per head never went direct to practices.

In the new contract the primary policy objective is the introduction of primary care networks.  As with access in the GPFV, the real new money follows the policy objective, not the demands of the service.

There was never £2.4bn additional funding.  The GPFV struggled right from the outset with transparency over the funding.  It was very difficult to track and find the money.  Some of us persisted in trying to track it down, and it turned out the extra £2.4bn never really was £2.4bn.  It was less than £1bn.  Headline announcements of large sums of money over 5 year periods are largely an accumulation of inflationary rises to the global sum.  And in the case of the GPFV these were backdated to before the document was even published.

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.

In the GPFV the headline figure was £2.4bn over five years, and in the new contract it is £2.8bn over five years. £1.8bn of the £2.8bn comes via the new networks, the rest is primarily in the uplifts to the global sum.  This year the uplift was 2.1%, less than the figures around 3% we were seeing during the GPFV.  But at least this time there is more transparency and the money is embedded in the contract.

5,000 extra GPs was always a myth.  One of the government’s promises when it published the GPFV was to provide an extra 5,000 GPs.  This became a particular source of embarrassment for the government, as not only did it fail to provide the extra GPs but the total number of GPs actually fell.  In 2019 there were 6.2% fewer full time equivalent GPs than in 2015[1].  At that point the old trick of changing the way the numbers are counted was introduced (see here[2]) to try and prevent further embarrassing comparisons.

With the 2019 contract the move was to additional roles to support GPs via the Additional Role Reimbursement Scheme.  How successful this is in supporting practices with the core workload remains to be seen.

It started the journey of delivering care in new ways.  The GPFV promised to support practices to introduce new ways of delivering care, and the Releasing Time for Care programme and the work of people like Robert Varnum on the 10 high impact actions were amongst the most helpful parts of the document.  However, there is no getting away from the fact that it was Covid-19 not the GPFV that has ultimately led to a step change in the way that care is delivered.

But for all its faults, the GPFV did represent a clear change in government policy towards general practice.  Previously, ever since the introduction of the revised GP contract in 2004 which the government felt it had paid too much for, there had been disinvestment in the service over many years.  This had left general practice in a parlous state, and it was only the introduction of the GPFV that really marked the end of this period of austerity.

However, for many this came too late, and the GPFV struggled to stop the exodus of GPs either into retirement or reducing their hours.  As a result the plan was never able to address the core workload and recruitment issues the service faced.

Five years on general practice is starting to feel different, but that is primarily down to the new contract and Covid-19.  The next few years are critical for general practice, particularly in terms of whether it can access the PCN funding to support the delivery of core services and build a sustainable staffing model, and whether it can embed the more helpful changes made during the pandemic. At least with a clear contract now in place the service has a more secure platform than the GPFV ever was to build on.

[1] https://www.bmj.com/content/bmj/369/bmj.m1437.full.pdf

[2] https://digital.nhs.uk/data-and-information/publications/statistical/general-and-personal-medical-services