24
jun
0

The Future of Federations

Posted by Blogs, The General Practice BlogNo Comments

What is the future of GP federations?  Do they have one, or does the emergence of PCNs mean that the days of GP federations are essentially over?

The best place to start when searching for answers to questions like these in the NHS is generally the wider policy context, and this is no exception.  The existing set of GP federations can be by and large split into two categories.  The first set of federations formed in c2007 at the height of the commissioner/provider split, when ‘world class commissioning’ was a thing, and when a primary care provider vehicle was needed for the delivery of services in primary care.

The second set of federations formed 10 years later in c2017 in response to the extended access funding that was made available to general practice and in response to the increasing pressure that general practice was finding itself under.  Funded through the delivery of the access hubs, federations were able to play a wider role in supporting individual member practices.

But the end of the commissioner/provider split was formally (if not explicitly) announced by the publication of the Long Term Plan in January 2019.  It signalled instead a shift to integration.  System Transformation Plans (STPs) were to be implemented and Integrated Care Systems (ICS) developed.

Over the last 30 years a range of GP commissioning organisations have all come and gone, from GP fundholding, through primary care groups and practice based commissioning organisations, right up to the current embodiment as CCGs.  These are in terminal decline, as the NHS moves to replace the legacy of commissioning organisations with the new integrated arrangements.

The new, non-commissioning, integrated entity for general practice are Primary Care Networks (PCNs).  First mentioned in the Long Term Plan published at the start of 2019, they are described as the enabler of “fully integrated community based health care”.

Without a commissioner/provider split, and with the establishment of PCNs as the statutory (or as close to statutory as can be achieved with a set of independent contractors) integrated community provider, it is not clear what role a separate primary care provider like a federation can play.

So far existing federations have been able to co-exist with PCNs, primarily by using the funding in their extended access contracts.  But the funding for extended access shifts to PCNs next year.  While federations will struggle to replace the lost income, PCNs will continue to grow and develop as integrated community providers, with nationally mandated funding streams alongside additional local ones.

It will be tough for federations to continue to exist in isolation from PCNs.  PCNs mean there is no need for a separate provider arm of general practice within an integrated care model, because PCNs are that provider arm.  In the world of integrated care, without the commissioner/provider split, where does an independent provider like a federation receive its funding from?

The future of federations, if there is to be one, can only lie as an enabler of PCNs.  The real barrier to progress for many PCNs is their size, and by working together through a federation they can move faster and more effectively than they can on their own.  Federations could take on delivery of extended access, and indeed of a range of PCN delivery requirements, but only if the PCNs want them to do so.

Federations are currently viable as a result of the provider contracts that they hold.  As integrated care develops, these contracts will shift into the realms of PCNs and the joint working between the statutory providers.  Crunch time is coming soon with the shift of the extended access contracts, and it is hard to see federations surviving it if they are not built on joint working between PCNs.

17
jun
0

accuRx – How General Practice was changed in one weekend

Posted by Blogs, The General Practice BlogNo Comments

On Monday 9th March Jacob Haddad, co-founder of accuRx, tweeted, “Friday PM, we decided to build two new products for COVID-19: video consultations and pre-appointment screening. Last night we shipped. This AM we tested. 3pm today, we enabled for 3600 practices – over half the country.”

By the end of April 35,000 video consultations were being carried out by general practice each day, across 90% of practices.  It is unlikely general practice will ever be the same again.

Who are accuRx?  Jacob Haddad and his co-founder Laurence Bargery launched the company in 2016 to develop datasets and tools to help tackle the problem of inappropriate use of antibiotics.  They quickly shifted to the development of a broader communication platform connecting clinical teams with patients.

They started with a text messaging service.  It gained traction quickly, in part because it was offered for free, and in part because GPs found it so easy to use.  It worked effectively with the GP clinical systems and made it easy to text patients where letters and phone calls were proving time consuming and ineffective.

But the game changer was this over-the-weekend introduction of video consultations.  In the past video consultations had been difficult to implement, because it was hard to synchronise timings between doctors and patients, and technical and installation issues often got in the way.  But the accuRx system is simple to use for both doctor and patients.  It makes it easy to switch from telephone to video, and doesn’t require any installation.

It is fair to say that GPs by and large love it.  It is extremely rare for a new technology to get universal uptake so quickly.  Of course the shift was shaped by necessity and the context of the pandemic, but even so it has been an unprecedented change, and one that is likely to shape how general practice operates for years to come.  And it is free: accuRx does not charge practices to use the service.  Apparently some agreement has been reached between the company and NHS England, the details of which are unclear, but it remains free at the point of use for practices and their patients.

accuRx is venture backed.  It raised £8.8M of funding in its last round in 2019, and is in what is termed the “pre-revenue” stage.  How that will play out for the NHS and general practice when it needs to generate revenue remains to be seen.  But the strategy of gaining traction for the product first has had a huge, transformational impact.

It is in direct contrast to GP at Hand, in many ways the initial trailblazer for video consultations.  GP at Hand set up in competition with general practice, using video and e-consultations as their competitive advantage.  They (unsurprisingly) encountered huge resistance, and now their advantage has gone.  While accuRx has thrived during covid, and undoubtedly has the support of the profession, apparently GP at Hand has furloughed 5% of its staff.

When you reflect on the millions and millions of pounds invested in technology within the NHS (NPFIT anyone?) and the tortuous pace of development, it is unthinkable that changes developed by a small team over the period of one weekend could have such a profound and permanent impact on general practice.  But that is undoubtedly what has happened, and general practice will never be the same again.

10
jun
0

Time for Reflection

Posted by Blogs, The General Practice BlogNo Comments

I am tired.  It has been difficult over the last few months not only having to keep up with the pace of change, but also having to constantly adapt and get used to new ways of working.  It is not only our professional lives, but our personal lives as well.  Everything we do has been completely changed.  It has been exhausting.

I know I am not alone.  Everyone working in general practice has had their world turned upside down.  All we want is some respite.

The talk nationally is of recovery and restoration.  Sounds like exactly what we need.  But of course it is not about us.  It is about restoring the services that are not being offered, and creating that dreadful term “a new normal”.

It is into this context that we hear about how this is a new future for general practice, how we must build on the changes and go further, faster.

But we are tired.

It may be the start of a new future for general practice.  Or it may be that many GPs are just waiting for the opportunity to close the much-touted new digital front door.  The draw of the comfort of ways of working that we know and trust may well take many back to how things were, not forwards to the newly glimpsed but (for some) highly uncomfortable ways of working we are now experiencing.

Recovery and restoration in general practice needs to start with practices and practice staff.  It needs to be about creating time for teams to reflect on the changes they have made over the last few months, to share the things that been difficult and to ask for help where it is needed.  We need the opportunity to talk to others about what they have done, how they have coped with the changes, and what the impact has been for them.  We want to learn from what they did differently and understand what this teaches us about our own experiences as well as theirs.  We need the comfort of knowing we are not the only ones who have found this difficult, and the reassurance that what we are doing now is ok.

We need time to consider whether any of the changes have been positive, and if they have which ones we want to keep.  We need the opportunity to think this through for ourselves, rather than be told it by other people.  We need to do this at our own pace.

At this point in our covid journey, I don’t think there is anything more important than creating time and space for reflection and review.  We have to recognise that we and those around us are tired, that change is difficult and this feels like it has been going on for a long time.  We need to create the opportunity for ourselves and our teams to be able to move forward.  It may feel counter intuitive, but the way to do this is by creating the time and space for our teams to look backwards, so that we can decide for ourselves where we go from here.

3
jun
0

Are PCNs Making General Practice More or Less Resilient?

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Resilience is a popular term at present, as we all cope with the challenges of covid in our own way.  While our individual levels of resilience may vary, it is not just our personality that will determine our overall level of resilience.

For GPs and those working in GP practices, the robustness of the GP practice itself will be a huge contributor to our personal resilience.  If our practice is well run, has strong leadership in place, and has good relationships across the practice, we can use the practice a resource to help us with the challenges we face.  When we are confident in the strength of the practice as a unit, we can draw on that to help us when things like covid come along.

Conversely, if the practice has divided leadership, poor systems and processes in place, and weak relationships between the staff, then the practice is likely to be a source of worry and concern for us.  The practice itself becomes yet another contributing factor to the stress and anxiety we feel, and so is likely to make us less resilient.

And so the strength of the practice unit is critical to the overall resilience of general practice.  So what impact do PCNs have on the resilience of GP practices.  Do they help, or do they make it worse?

For some practices, the PCN is a real source of concern.  We have seen this articulated in some of the resistance to the PCN DES.  PCNs are designed so that the performance of the individual practice becomes linked to the performance of the other practices in the PCN.  The inability of your practice to control the performance of the other practices in the network, alongside a lack of confidence in their ability to deliver, means the PCN will serve primarily to reduce our confidence in our own practice’s ability to deliver.  Putting performance outside of our individual control is a source of stress and detracts from our overall resilience.

The desire to maintain the independent contractor model in the context of PCNs is about enabling a practice to keep control of everything within its contract, and not allow concerns about other practices to make the job of running your own practice even more difficult.

For others, however, particularly as a result of the recent challenges of tackling covid, the PCN has become a source of real strength.  While I as an individual practice may not have been able to cope with covid on my own, by working with the other practices in my PCN I found support, joint working, and a collective strength that enabled the challenges we faced to be overcome.

By working with other practices I trust I can become more confident in the delivery of targets because I can access the support and help I need when things are difficult or I don’t know what to do.  The PCN becomes a vehicle for sharing of ideas, information and resources that means I feel more confident about my practice, and so more resilient overall.

So are PCNs making general practice more or less resilient?  It varies.  Some practices feel that the PCN makes their practice less resilient, while others are starting to feel that their resilience is very much improved by being part of the PCN.  The most interesting thing about this is that practices control the PCN.  PCNs can support the resilience of general practice, but ultimately it is up to the practices in the PCN to decide to work on building the trust and relationships required to enable this, or whether to resist the PCN, treat it as a threat, and suffer the impact on overall resilience that will result.

27
may
0

The Opportunity of the Additional Role Reimbursement Scheme

Posted by Blogs, The General Practice BlogNo Comments

By far the largest amount of funding in the PCN DES is for the Additional Role Reimbursement Scheme (ARRS).  But is general practice making the most of the opportunity that such an investment represents?

To put the funding into context, a PCN with a weighted list size of 50,000 will receive £356,600 under the ARRS.  This size of PCN will have funding for more than 7 roles this year.  This will rise to £618,600 next year, £850,900 the year after, and reach £1.17M in 2023/24 (network contract DES guidance p20). The £7.13 per weighted patient PCNs receive for the ARRS for this year compares to a combined total of £5.61 for all of the other funding in this year’s specification put together (excluding the care home premium, which is not going to significantly alter the figures).

The funding is not, however, given as a lump sum.  It is paid a month in arrears based on the actual expenditure made by the PCN.  A PCN must, “complete and return to the commissioner a workforce plan, using the agreed national workforce planning template, providing details of its recruitment plans for 2020/21 by 31 August 2020 and indicative intentions through to 2023/24 by 31 October 2020” (6.5.1 Network contract DES Specification, p36).

We are currently at the end of May.  Assuming a PCN has not yet employed any additional staff (although I know some have, many have not), our 50K weighted population PCN now has funding for 9.3 additional roles.  If the PCN waits until the end of August (the deadline for submitting its plan), it will have funding for 11.6 additional roles.  The longer we go into the year, the harder it is going to be to spend the money.  Once we are over a third of the way in next year’s funding is unlikely to cover the incurred recurrent expenditure even if we do manage to spend it all.

Any money allocated to a PCN that can’t be spent will be offered to “other PCNs within the commissioner’s boundary”.  So a smart PCN will not only be well into planning how to use its ARRS funds, it will also be looking at its neighbouring PCNs and working out whether they going to be able to use all their funding and preparing accordingly.

This year, impacted already by covid as it has been, does present general practice with something of an opportunity when it comes to ARRS.  In effect there is 12 months funding available for 6 months of work, because the requirements of the specifications only start on October 1st.  The argument has been that the roles should be supporting core general practice, not simply carrying out additional work mandated by the PCN DES.  Well it may or may not be by design, but that opportunity is certainly there now for this year for PCNs.

The question, then, is how should PCNs respond?  With such a wide array of roles (10 in total) available, what roles should PCNs be prioritising?

Let’s take the work to meet the requirements of the specifications as a given, and focus on what to do with the roles beyond that.  The specifications are not going to require all of the ARRS funding, and certainly will not this year.  Once the specification requirements are met, it seems there are two ways to think about how to use the new roles.

The first is to focus on the roles that will free up the most GP time.  The biggest challenge in general practice for a long time now has been GP workload, and so it would be logical to use this funding on the roles that most directly reduce GP workload.  This would lead to a focus on first contact physiotherapists, physician associates, pharmacists and (next year) paramedics, as roles that can directly have this impact.

The second is to focus on the roles that can change the shape of demand into GP practices.  Instead of reacting to the incessant rise in demand on practices, this may be an opportunity to do something about it.  A team made up of some combination of social prescribers, health and wellbeing coaches, occupational therapists, dietitians, podiatrists and care coordinators may be able to start with the currently shielded and housebound patients, and prepare a PCN for the anticipatory care and personalised care specifications that are on their way in future years.  By proactively meeting the needs of those patients who are the biggest drivers of demand on PCN practices, the constantly rising demand may be slowed.

These two approaches are not mutually exclusive.  It may be that some combination to the two is what is needed locally.  And of course there may be others.  What is important for PCNs is to be clear on what they are trying to achieve with the new roles, before they start deciding which specific roles they want to employ.

It is rare that general practice finds itself with an opportunity like this, backed up with such significant resources.  I very much hope we make the most of it.

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