17
mar
0

Who is looking after General Practice?

Posted by Blogs, The General Practice BlogNo Comments

This pandemic has not been just one big challenge, but rather a whole series of different challenges over an extended period of time.  As we move into yet another phase, and the next set of challenges, where does the energy come from to keep going?

At first there was the arrival of the pandemic itself, changing the operating model and moving to remote working, and putting systems and processes in place for managing patients presenting with Covid symptoms.  Then we had to work out how to do this alongside the normal work of general practice.  Then we had to introduce a vaccination programme, which has been all consuming and itself a series of different challenges (different vaccine types, care homes, housebound, practice dispersal etc etc).

One year in, we are once again moving into a new phase and a new set of challenges.  Some of the core services (such as QOF) that were put on hold are restarting.  The vaccination programme continues.  The work of PCNs accelerates, as the ARRS nearly doubles in size and the move towards integrated care means PCNs have to start to play an important role in influencing the system as whole.

But are we ready for more challenge?  How do we find the energy and personal resources to cope with and manage more change, more disruption, and yet more new ways of working?

We have not been good in the NHS at looking after the people who work in the service, or indeed at looking after ourselves.  We have known for a number of years that most GPs are looking to reduce the number of hours they work, and a large percentage of those who can are planning to retire in the next five years.  It is not just GPs; many practice managers and other members of the practice team are also looking to leave.  The recent pay offer for NHS staff and the freeze on the lifetime pension allowance is not going to help.

The continual wave after wave of challenges the pandemic is creating has made this situation more critical than ever.  If we do not take time now to look after ourselves, and look after the people we work with, it wont be long before the exodus of people out of general practice reaches unprecedented levels.

We have to prioritise our staff and ourselves.  The good news is that there are actions that we can take.  In this week’s podcast I talked to resilience expert and GP Dr Rachel Morris.  She outlined a range of tools, techniques and approaches that can all help with personal and team resilience.

It seems to me that the starting point is deciding that looking after ourselves and our teams is the priority.  We cannot rely on or even expect other people, or the wider NHS, to do that for us.  Most people working in general practice have spent a lot of time doing whatever has been needed to meet the different Covid challenges.  Going forward the only way general practice is going to be in a position to serve its local populations is by ensuring it takes time now to invest in itself and the people who work there.

10
mar
1

ARRS Roles: Planning for Year 3

Posted by Blogs, The General Practice Blog1 Comment

We are about to embark on year 3 of the Additional Role Reimbursement Scheme (ARRS), through which the PCN DES funds additional roles for individual PCNs.  How can we take the learning from the first two years and build it in to our planning for next year?

The first year of the ARRS was relatively quiet, as PCNs were only allowed to employ a pharmacist and a social prescribing link worker.  Last year the scheme took off, in part because the list of different roles was expanded to 10, and in part because 100% (as opposed to 70%) of the salary costs were reimbursed through the scheme.

The investment into roles through the scheme continues to increase significantly into year 3, with the total investment reaching £746M nationally.  Many PCNs will be in a place where they can afford 10 or even more staff with the funding available. This number will continue to rise for the next two years.  What this means is PCNs have to move from considering the ARRS staff on an individual basis to thinking about all of the roles collectively as a team.

I have written previously about the challenge of introducing the new roles.  This challenge just gets greater as the number of roles increases.  We are now at a tipping point where the overall approach needs to change.

Any business that employs 10 or 20 staff would put a business plan in place.  Having a plan is what is now required for PCNs.  The plan needs to contain (as a minimum) the following 4 elements:

  1. Team Objectives

PCNs need to clarify exactly what the objectives for the ARRS team are.  How will the PCN know at the end of the year whether the new team has been a success?  How will the team itself know?  How will the practices know?  Agreeing objectives for the team will help everyone, and help move the PCN away from a mentality that it is recruiting these roles simply because the funding is available.

  1. Team Structure

The retention challenge for these roles is something I have already written about, despite the recruitment only really taking place in earnest over the last 9 months.  It is clear the individuals in these roles need to feel part of a team.  At the same time, practices cannot simply absorb the extra work of looking after these roles, and asking them to do it means in many cases it simply does not happen.

My sense is most PCNs will need to create an overall ARRS team.  Very large PCNs can probably create more than one team, such as a pharmacist team and a social prescribing team, but the majority of PCNs will need one team so that the individual Health and Wellbeing Coach (for example) does not end up being isolated.

The team will need a leader.  It needs to be someone’s job to be responsible for the overall ARRS team.  This does not mean line managing every member of the team, but it does mean responsibility for ensuring the team is functioning effectively, delivering on its objectives, has effective communication across it, and that any issues that arise are dealt with.  This could be the Clinical Director or PCN manager, but someone needs to take on this role.

The team needs to have a structure.  Moving beyond 5 or 6 members of the team means that there needs to be levels within it, e.g. one of the pharmacists managing the other pharmacists, a senior link worker managing the other link workers etc.  Planning the structure, thinking about individual advancement, making the team more self-sufficient are key aspects of this part of the process.  No structure means as more staff are recruited, the burden simply becomes greater on a relatively small number of individuals.

  1. Team Support

The key retention question for the PCN is how will this team be supported?  The provision of support is critical to getting the most out of them.  There are plenty of examples up and down the country of either ARRS staff such as Physician Associates carrying out low level work because no clinical support is being provided, or of staff such as social prescribing link workers working to other agendas because what support there is is provided outside of the PCN.

Increasingly there are opportunities (e.g. for pharmacists here or physician associates here) to ensure ARRS staff receive the training they need.  We are beginning to understand better how work needs to be organised to ensure ARRS staff can be effective (e.g. for FCPs here).  The PCN plan needs to be explicit about exactly how the ARRS staff will be supported.

  1. Team Finances

As the team expands the financial model of matching the monthly cost of the ARRS staff against the reclaimable allowance is no longer sufficient.  This is an important element of the financial plan, but cannot be it in its entirety.

The ARRS team are a (funded) investment in the wider work of the PCN.  There are wider costs beyond those which can be reclaimed, e.g. clinical supervision, line management, estates costs, training costs.  PCNs also need to be mindful of potential VAT costs as they are likely to exceed the £85,000 VAT threshold, and of the need for a fund to cover potential employment liabilities.  Equally, income can come from other sources such as CCG/HEE/ICS funding pots, PCN core and development funds (etc), as well as benefits in kind provided to practices (e.g. support for vaccination services, a home visiting service, support with the delivery of enhanced services etc).  There are also future opportunities on the horizon, such as support with the delivery of extended access.

The funding model is not perfect, but for the ARRS team to be effective a financial plan for the team as a whole needs to be put in place.  This is more important this year than it was last year, and its importance will continue to increase year on year as the total amount of ARRS funding received (and associated costs) grows.

 

The plan does not need to be long or complicated.  But spending some time and energy now in putting a plan together will put the PCN in a much stronger position for making the most of the opportunity of these new roles in the year ahead.

3
mar
1

Does Integration Really Mean Centralisation?

Posted by Blogs, The General Practice Blog1 Comment

I wrote last week about the new White Paper published by the government, and what it means for general practice.  My sense at the end of the White Paper is that I am less clear now than I was before as to what exactly is meant by “integration”.  Does it mean removing the barriers between organisations to enable joined up care, or does it in fact mean a further centralisation of control?

I understand the logic of integration, and why it is perceived to be a ‘good thing’.  Years of an internal market have created divisions and rivalries within the health service, and led to behaviours focussed on the needs of individual organisations rather than necessarily what is best for the patient.  It makes sense, then, to take steps to remove these artificial barriers created by the system, and for the organisation of care to be centred on what is best for patients.

There is, however, a difference between removing the barriers that have prevented health and social care professionals from working across organisational boundaries and centralising control into single organisations.

The new statutory NHS Integrated Care System (ICS) bodies will be given more formal power, “In order for ICSs to progress further, legislative change is now required to give ICSs stronger and more streamlined decision-making authority” (White Paper 5.4).  Further “each ICS NHS body… will be directly accountable for NHS spend and performance within the system” (6.18 f).  The NHS is well known for its mindset that accountability cannot be exercised without control.  Indeed, the system’s experience of the regional tiers of NHS England points very much to the fact that centralised control is something NHS England is extremely comfortable with.

All organisations within the NHS will not be merged into these new ICS bodies.  How, then, could control be exercised by the new system?  Well there are “several further changes to reinforce or enable integration” (the actual words used, 5.13 of the White Paper), one of which is a new “duty to collaborate” (3.11) imposed on all organisations across the system.  It does not take a huge stretch of imagination to envision a situation where any organisation not complying with the central diktats of the new ICS are taken to task for failing to comply with the new duty to collaborate.

The White Paper does talk about “the primacy of place” (6.5), and by place it means local areas within an ICS, but it only goes on to say that place is important, and not how this primacy should be effected.  Instead the government is not, “making any legislative provision about arrangements at place level – though we will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14).

Worrying, then, that a centralist-minded ICS would be able to set up its own arrangements for how arrangements in local “place” areas will work, with as many control mechanisms as it likes.  The argument is that by not legislating the arrangements that work best in any local area can be made, but that does leave it wide open to local interpretation/abuse.

We are therefore left with a situation, embedded by a new legislative framework, that seems designed to bring about integration not through relationships but through a system of centralised control.  How it works in practice will be dictated by the way NHS England behaves with the new ICS’s, and how the local leaders then operate within their own area.

Now I am generally a glass half-full individual, and of course there will be local leaders who focus on empowering and enabling local teams.  But I suspect this will be the exception rather than the rule, and so all of this leaves me feeling less than optimistic about the future.

24
feb
2

What does the new White Paper mean for General Practice?

Posted by Blogs, The General Practice Blog2 Comments

White Papers are not known for their readability, and at 80 pages long it easy to understand why the White Paper published on the 11th February has not made it to the top of the reading list of GPs busy dealing with the pandemic.  But how important a document is it, and what implications does it have for general practice?

The document signals three changes important for general practice:

  1. The Primacy of Integration
  2. Integrated Care Systems to become Statutory Bodies
  3. Locally Determined Place-based Arrangements

 The Primacy of Integration

At the core of the changes proposed is a shift away from the internal market and towards joined up, or integrated, care.  The aim is to continue to bring different parts of the systems closer together, and to support “GP and healthcare specialists to work together to arrange treatment and interventions that either prevent illness or prevent their conditions deteriorating into acute illness” (4.2).

Integration does not mean merger.  “While NHS provider organisations will retain their current structures and governance, they will be expected to work in close partnership with other providers and with commissioners or budget holders to improve outcomes and value.” (6.8)

There is, however, a new duty to collaborate. “This will require health bodies, including ICSs, to ensure they pursue simultaneously the three aims of better health and wellbeing for everyone, better quality of health services for all individuals, and sustainable use of NHS resources.” (3.11).  One assumes this will equally apply to general practice.

The expectation in recent years has been for GP practices to work together and in partnership through Primary Care Networks (PCNs).  While the White paper says very little directly about PCNs, it certainly signals integration as the direction of travel moving forward.

Integrated Care Systems to Become Statutory Bodies

Integrated Care Systems (ICS’s) are not new, as most areas already have one, and the White Paper is very much about legislation catching up with what it already happening.  However, as a result of the proposed legislation the ICS’s will become statutory bodies.

Each ICS “will be made up of an ICS NHS Body and a separate ICS Health and Care Partnership, bringing together the NHS, local government and partners. The ICS NHS body will be responsible for the day to day running of the ICS, while the ICS Health and Care Partnership will bring together systems to support integration and develop a plan to address the systems’ health, public health, and social care needs.” (3.9).

Why separate the ICS NHS body and the ICS Partnership?  The White Paper explains that the creation of an ICS NHS body is needed to, “merge some of the functions currently being fulfilled by non-statutory STPs/ICSs with the functions of a CCG. We aim to bring the allocative functions of CCGs into the ICS NHS body so that they can sit alongside the strategic planning function that we would like the ICS to undertake” (5.8).

Effectively then the role of CCGs become subsumed under the ICS NHS statutory bodies, who will take on both responsibility for allocating NHS money and the commissioning of general practice. However, interestingly, “It will not have the power to direct providers, and providers’ relationships with CQC will remain unchanged.” (6.15 e)

So the days of general practice being responsible for NHS money – the claim made when CCGs were introduced – will formally be over with the introduction of the new ICS NHS bodies.  General Practice will still have a say, however, as, “Each ICS NHS body will have a unitary board, and this will be directly accountable for NHS spend and performance within the system, with its Chief Executive becoming the Accounting Officer for the NHS money allocated to the NHS ICS Body. The board will, as a minimum, include a chair, the CEO, and representatives from NHS trusts, general practice, and local authorities, and others determined locally for example community health services (CHS) trusts and Mental Health Trusts, and non-executives.” (6.15 f)

In addition to this statutory board, ICSs and NHS providers can create joint committees and delegate decisions to them. At the same time NHS providers can form their own joint committees.  These are relevant for general practice as, “Both types of joint committees could include representation from other bodies such as primary care networks, GP practices, community health providers, local authorities or the voluntary sector” (5.26).

It will be important for general practice to ensure it both has representation and get its representation right on both the local statutory boards and joint committees.

Locally Determined Place-based Arrangements

An important term used in the White Paper is that of “place”.  By place it means local areas within a larger ICS, “Most usually aligned with either CCG or local authority boundaries… Many provider organisations and groupings of organisations such as primary care networks look to their ‘place’ as their primary focus” (6.5).  Place, then, is not a PCN, but the local area within which a PCN operates.

The White Paper does not propose any legislative arrangements at a place level, although they, “will be expecting NHSE to work with ICS NHS bodies on different models for place-based arrangements” (6.14) – i.e. expect guidance to come.  Local Authorities will have a big say in these place-based arrangements, which include aligning ICS allocation functions (i.e. where the money goes).  Health and Wellbeing Boards are explicitly recognised as having “the experience as place-based planners” (5.11), and so will feature in the local arrangements.

Local place arrangements may well end up being the ones that impact general practice and PCNs most.  Individual areas will have more of a say as to how these end up as they are outside of the scope of the new legislation, so it is important GPs and PCNs start to influence now how these develop locally.

 

Overall the White Paper signals a continuation of the changes already started across the NHS.  It does means a new contract manager for general practice (the new ICS NHS body), but more importantly it requires general practice to work in partnership with other organisations, and those partnerships will be pivotal to its future success.  Little if anything is said in the White Paper about PCNs and their future role in the new system, but everything suggests PCNs will be the key enabler of these partnerships.

17
feb
0

The Changing Face of At-Scale General Practice

Posted by Blogs, The General Practice BlogNo Comments

It is not long ago that at-scale general practice primarily meant the merger of practices into bigger practices, the emergence of super-partnerships and the development of GP federations.  But all that has now changed.

This change has come about because the unit of at-scale general practice has changed.  It is now the Primary Care Network.  The PCN is the unit through which investment is made into general practice, through which delivery is expected, through which the workforce is being developed, and through which general practice will have its voice within integrated care systems.

Historically practices were moving towards at operating at greater scale for three reasons: financial, workforce and influence.  In the last two years since PCNs came into existence it has become abundantly clear the best way for general practice to achieve any of those gains is through PCNs.

As with any change, there are winners and losers.  Those most adversely affected are the large and dispersed super-partnerships, and GP federations.

The large super-partnerships spread out across large geographical areas were built on the establishment of a centralised resource whose cost was prohibitive for small partnerships, but is continually reduced by larger and larger numbers.  These partnerships worked to grow their numbers across the country, and in doing so reduced costs and overall profitability.  But PCNs are based on co-located practices serving specific communities rather than isolated practices joined together by a shared central resource, and so the new PCN environment will not enable this model to thrive.

GP federations were a relatively safe unit of at-scale general practice, that allowed practices to retain their individual identity and ways of working but come together on shared initiatives to secure contracts (such as extended access) and funding (such as for GP Forward View work like care navigation and workflow optimisation).  But with practices now within PCNs, and PCNs receiving any shared initiative funding including extended access, the future for federations as a model for individual practices working together seems very limited indeed.

But the shift of focus of at-scale general practice also creates opportunities.  The biggest opportunity comes for practices working together within a PCN.  The closer those practices can work together, and blur the lines between core practice business and PCN business, potentially to the point of full merger, the greater the opportunity for those practices to use PCNs to stabilise and sustain the core practice model.  If the practices can incorporate the ARRS roles along with the PCN DES requirements into its core business, they have a much greater chance of a sustainable long term future than those that treat all of the PCN investment and work as separate to core business.  We will see this disparity magnified as extended access moves into the jurisdiction of PCNs.

The other main opportunity comes for practices to change the function of their federations.  As I have discussed previously, the limits that PCNs put around at-scale general practice (ongoing and increased individual partner liability, a disparate voice across multiple PCNs within an integrated care system area, a limited ability to support and maximise the value of the new ARRS roles) can all be overcome by PCNs working together within a federation.  While the unit of scale for individual practices is now the PCN, the unit of scale for PCNs could usefully become the federation.

Like it or not PCNs are now established as the primary unit of at-scale general practice. The question for practices to consider is how best to adapt to make the most of the opportunities of this new environment.

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