15
may
1

PCN Deadline Day: 8 Lessons we have learnt so far

Posted by Blogs, The General Practice Blog1 Comment

Primary Care Network submission day has arrived!  3½ months have passed since Primary Care Networks were formally announced as part of the new GP contract for 2019.  What have we learnt in the intervening period?  I would suggest there are (at least) 8 key lessons.

  1. PCNs represent the biggest change for general practice in a generation. While PCNs may have started life as only one part of the package that was the 2019/20 GP contract, it has become clear they represent a much more fundamental change for general practice.  Funding flows into the profession are set to shift from being primarily at an individual practice level, to being primarily at a PCN level.  The fates of GP practices within a PCN are set to become inextricably intertwined.
  2. 15th May was an ambitious deadline for PCN submissions. The initial expectation was practices would have their network agreements in place by today, but as the complexity of that particular task became clear the deadline for the full agreement was relaxed to the end of June.  Practices choosing whom to get into bed with has taken most of the last few months (and some may still not be there yet!), and the challenge of defining the nature of the agreement between them still lies ahead.
  3. The lawyers are coming. What wasn’t clear at the outset was how defined the nature of the network agreements between the practices needed to be.  NHS England has produced a “legally binding” mandatory network agreement for all practices to sign up to, but the meat of this agreement has been left to schedules that need to be developed and agreed locally, which will inevitably require lawyers.  It will be hard to keep the focus on trust and building relationships, which is widely agreed to be the most important foundation for a successful network, once the lawyers are in.
  4. Focus has shifted away from the sustainability of core general practice. In the context of the new GP contract, PCNs were heralded as the mechanism for enabling new funding and resources to flow into general practice.  But on top of the legal fees, each new role requires practices to dip into their pockets to finance the unfunded elements, and the funding for extended hours has been cut.  The talk surrounding PCNs has quickly moved towards “system integration” and equally quickly away from the sustainability of PCN member practices.
  5. The gap in funding for new roles is high risk. As practices have picked through the funding of the new roles, they have found that the headline 70% is an optimistic assessment of the national contribution.  This contribution is fixed regardless of the local market for the roles, or the package the network ultimately has to offer.  Financial liability for the new roles, for example in the case of redundancy, also sits with the practices in the network.  Whether all networks take up the offer of the new roles remains to be seen, but it appears increasingly likely at least some will not.
  6. PCNs represent a shift in system GP leadership. CCGs always had the problem that they represented their population not their practices, despite being membership organisations.  The introduction of PCNs coincides with a 20% cut to the management costs of CCGs and a likely move to a wave of mergers, making CCGs yet more distant from local areas.  At the same time PCNs will each hold seats on the integrated care system boards, as the means of providing “full engagement with primary care” (Long term Plan 1.52).  There is a clear shift of power in motion from CCG GP leaders to PCN Clinical Directors.
  7. The role of Federations is uncertain. Federations were conspicuous by their absence from the Long Term Plan and the new GP contract, and it is clear that PCNs are flavour of the month.  It remains to be seen the extent to which PCNs will work together effectively through federations, or whether each PCN will plough its own furrow.
  8. Expectations of PCNs at practice and system level are very different. There are grand plans for PCNs in the Long Term Plan, as the focus of developing place-based care and integrating services around local communities.  But the challenges facing front line GP practices have not gone away, as the recent Panorama programme highlighted.  Practices need PCNs to first support and enable their sustainability, whereas the system expects them to first prioritise delivery of their own plans.  How that tension plays out remains to be seen.

We are still at the very outset of PCNs.  Establishing them may have been the easy step, compared to some of the questions that remain unanswered and the challenges that lie ahead.

8
may
0

Will the PCN Voice really count?

Posted by Blogs, The General Practice BlogNo Comments

The Long Term Plan published in January of this year said, “Every integrated care system will have… full engagement with primary care, including through a named accountable Clinical Director of each primary care network.” (1.52)

The GP Partnership Review, published shortly afterwards, said, “Working at scale, for example through Primary Care Networks, has the potential to improve and support general practice influence at a system level.” (p35)

The question is will the establishment of PCNs and the new Clinical Directors really mean that general practice has a voice, and be able to influence outcomes (and the flow of resources) at a system level?  You could argue the establishment of Clinical Commissioning Groups as statutory bodies was supposed to achieve just that, yet they have presided over one of the worst periods of under investment into general practice in NHS history.  Clearly setting up an infrastructure doesn’t of itself necessarily translate into a bigger voice.

Of course, some might argue, CCGs were commissioning organisations and PCNs are provider organisations, so this time it is different.  It is hard for the average GP not to be cynical about yet another promise that “this time it is different”, after so many previous identical promises failed to deliver.

We are heading in the direction of c1000 Primary Care Networks (PCNs) across England.  There are 44 STPs, so we are looking at c20 PCN Clinical Directors per STP.  Even though this is hugely more manageable for system leaders than 7,000 GP practices (c150 per STP), it is difficult to overestimate the challenge for each one of those 20 Clinical Directors trying to influence for their particular PCN.

In the model of “place-based care” (NHS-talk for providers from across health and social care working together at a PCN level), you could argue PCN Clinical Directors will be leading and shaping the integration of services locally.  However, this also depends on whether the reality of how place-based care works is bottom-up (decisions made by local teams), or top down (decisions made at STP level, and PCN leaders asked to implement them).  This in turn will depend on how influential the PCN leaders are at STP level.

The challenge facing the new Clinical Directors of PCNs is formidable.  They have to introduce joint working across GP practices that have never really worked together previously, and manage all the inevitable internal disputes and conflicts that will arise, before they can even start thinking about how they will work with local partners, and how they will create a strong voice for local general practice.

My sense, however, is that it is important to start as you mean to go on.  While the odds may initially be stacked against PCN Clinical Directors, the reality is the system needs them more than they need the system.  There is the opportunity to influence, but only if it is seized and taken from the start.  It is not going to come on a plate, and the new leaders of primary care will need to work hard to establish their voice.  Done badly, the voice will not be strong.  But done well, I think there are many gains to be had for PCNs, their practices, and their local populations.

It is with this in mind that here at Ockham Healthcare we have created a brand new (free) guide for PCN CDs on how to establish an effective voice.  It includes 10 practical steps PCN leaders can take to make their voice effective.  If you are already on Ockham Healthcare subscriber you will receive the guide free via our weekly newsletter on the 9th May.  If you are not a subscriber just sign up here (for free) and we will email you a copy.  I hope you find it useful, and good luck with finding your voice.

1
may
0

Guest Blog – The new Primary Care Network Agreement

Posted by Blogs, The General Practice BlogNo Comments

This week our old friend John Tacchi returns with a guest blog on the newly published Primary Care Network agreement. A vital set of documents which will dictate the shape of PCNs for years to come.  John critiques the agreement…and doesn’t pull his punches.

NHS England has released the mandatory Network Agreement which all PCNs will have to sign. It consists of two documents, the agreement and the schedules. Given the importance of this document (bear in mind that in future, payments to GPs will increasingly be made to PCNs and less to individual practices), it is a bit thin. Terribly thin in fact. Rather than pick it apart, let us instead consider what it actually says and what is left in the hands of GPs to sort out for themselves.

The Agreement

This is the document that all members of the PCN must sign. It is categorically stated as ‘legally binding’ and so will govern the future relationship of the practices which make up the PCN and govern the flow of money. There are 106 clauses and you would be forgiven for thinking that this is where the ‘meat’ is. These cover general obligations and patient involvement, financial arrangements, workforce, information sharing and confidentiality, conflicts of interest, meeting format (governance generally), joining and leaving the PCN, duration and variation, termination, dispute resolution and ‘events outside our control’.

Except they don’t. The clauses in the agreement all refer to the schedules for greater detail. The schedules document is, however, a series of blanks, leaving PCN members to fill in as necessary. This is not particularly helpful and leaves GPs to sort out a host of vital issues themselves. The top 5 are:

Financial arrangements

There are so many issues under this heading. If one practice in the PCN is designated to receive PCN payments, how will it pay what is owing to other practices? When? On what basis (i.e. what happens if another practice does not provide the PCN services required)? How will be accounted for? What happens when there are other organisations other than practices involved? What about possible insolvency of a practice; how will this impact the PCN? What about intellectual property rights of individual practices/partnerships? How will these be protected? Can individual partners of member practices be sued for the liabilities of the PCN? No detail. Not good.

Workforce

Given the fact that money is being made available for additional roles (but not at 100% reimbursement), who will employ them? If the practice that is the designated fund-holder does, is it aware of the implications from an HR perspective? If another organisation employs them (i.e. a new company), there may be VAT issues. This has the potential to create horrendous problems.

Governance

How will the PCN decide on pressing issues? It will need to have some a ‘board’ of some kind and who will be on it? What will the role of Clinical Director be? Will representatives of the ‘board’ have authority to bind individual partnerships? What is the legal status of decisions made? What about liability issues? How will a PCN vary the agreement if it needs to? Many, many open questions.

Joining and leaving the PCN

This is probably the most glaring ‘omission’ (given the schedule simply says ‘fill in the blanks’). How do practices leave and are they even able to do so? Can a PCN expel a member practice? If so, how? If a PCN expels a practice, what becomes of the patient list? How will they still receive PCN services?

Dispute resolution

What happens if things go wrong? What is the legal status of member practices within the PCN? Who will act as arbiter in the event of a dispute?

Timing is obviously an issue. The network agreement and all its schedules must be signed by all member practices by June 30th.  This is not very far away! The current version does at least say that the agreement can be varied from time to time, but this first draft is so devoid of detail that PCN members really must get specialist advice before signing anything. Lawyers are expensive and it is only the national firms that have the breadth of experience to give a detailed view. They are very expensive. GP’s need specialist advice on this vital issue. And fast!

John Tacchi

Tanza Partners

www.tanza.co.uk

17
apr
1

Federations vs Primary Care Networks

Posted by Blogs, The General Practice Blog1 Comment

There is a tension developing in some quarters between the existing GP federation and the emerging Primary Care Networks (PCNs).  It is like they are trying to compete for the same ground (at-scale general practice), and the result is a growing discord between the two.

A conversation develops about what the federation “offer” is for the new PCNs: will it be for all of the £1.50 per patient running cost, or just a proportion of it?  And what do the PCNs actually get in return for this investment of their money?  Federations can feel they have to justify their offerings, and PCNs can feel they might not be getting value for their investment.

What about the existing work of the federation?  Much of it, such as the delivery of extended access, is funded through monies that in future will be coming through the PCNs.  Will this work continue in its current form, or will the new PCNs demand a different model of delivery to that insisted on by the commissioners?  If it changes, will the GP federation even have a future?

It is easy to understand why tension between the two develops.

For me, however, this tension misses both the point and the opportunity of general practice operating at scale.  Inherent to both PCNs and GP federations is a membership of GP practices (generally the same GP practices).  The point of working together (whether because they choose to or “have to” because of the new GP contract) is to be able to better serve these member practices and their populations.  This is true for both PCNs and GP federations.   The practices are the underlying constant.

So the best place to start the conversation between federations and PCNs is not who should be doing what, and how much they are going to be paid for it, but one between the member practices as to what the relationship between the two is going to be.  The conversation should really be between the practices themselves, working out what they want to do together at PCN level, and what at federation level, and then to organise themselves accordingly.

For me, the most logical step is for the new clinical directors of PCNs to either become the Board, or at least have a majority on the Board, of the GP federation.  This removes the unhelpful sense of competition between the PCNs and federation, and instead enables the PCNs (as the group closest to practices and that hold the majority of the funding) to ensure the federation delivers exactly what the PCNs need.

There is no reason why existing GP federation directors can’t stand and become clinical directors of the new PCNs.  I was asked recently as to whether this would be a conflict of interest.  This question only makes sense if your starting viewpoint is one of competition rather than collaboration between federations and networks.  If the role of the federation is to serve the networks, not only is it not a conflict of interest but it is a pragmatic response to the emergence of PCNs.

For areas that have a GP federation the opportunity exists to have the best of both worlds – scale where it is needed, and a focus on individual local needs.  A GP federation and PCNs working in harmony can secure more investment and resources, create efficiencies by reducing duplication, establish robust and tailored mechanisms for service delivery, limit liabilities, improve patient outcomes, and strengthen the collective voice of general practice.  But whether practices can take this opportunity may depend on their ability to ensure the conversation is focussed on how to deliver the most benefit to practices, rather than one that is competitive between the two.

10
apr
0

Primary Care Networks: Learning from the Past

Posted by Blogs, The General Practice BlogNo Comments

“What has been will be again, what has been done will be done again.  There is nothing new under the sun” Ecclesiastes 1:9.

Primary Care Networks (PCNs) may be the shiny new toy of today, but of course they are not completely new.  At their heart they are about practices working together, about the introduction of new roles, about securing a vibrant future for general practice, about joining general practice more closely together with the rest of the NHS, and about making a difference to local populations.  These are challenges GP practices have been grappling with for a number of years now.

In 2016 at Ockham Healthcare we started the General Practice podcast, and have featured case study after case study of GPs, practices and groups of practices who have been innovating and finding new ways of working to tackle these challenges.

We also published, “The Future of General Practice. Real Life Case Studies of Innovation and New Ways of Working”, in which we highlighted 16 of these case studies, analysed why they had been successful, and distilled the lessons that could be learnt from them. What strikes me now is that this learning is more relevant than ever, to accelerate the progress and impact PCNs are able to make, and to avoid the mistakes of the past being repeated.

The case studies include a focus on introducing new roles.  We considered the impact of pharmacists, first contact physiotherapists, and paramedics, and how they could reduce the workload of GPs.  Even more interestingly, we looked at the development of multidisciplinary teams in general practice, and in particular how in some places they have transformed the management of on the day demand and the whole experience of being a duty doctor in a practice.  Key lessons included starting with the person not the profession, keeping a focus on building a wider team not on individual roles in isolation, and the need to stage appointments of staff over time.

Just like new roles, working with other practices is not new.  There are many experiences out there of what to do and what not to do that those involved in setting up the new PCNs would be wise to pay heed to.  We looked at case studies of mergers over a time period, multiple mergers at the same time, as well as the establishment of a super-partnership.  A whole range of benefits of at-scale working were realised, such as improved resilience, a better ability to manage demand, and greater profitability.  However, we also found simply working at scale does not automatically generate these benefits, and highlighted some important lessons for practices working together to make these a reality.

A key focus of PCNs will be partnering with other organisations, but again this is not completely new ground for general practice.  In the book we considered case studies of practices working with a hospital, with a community trust, with community pharmacy, with the voluntary sector and the local community.  We looked at the benefits general practice was able to achieve through this, such as access to staff, back office support, financial gains, and also what factors seemed to make these particular relationships successful compared to areas where relationships are poor.

There are now less than 75 copies of “The Future of General Practice” left.  To help those who want to learn the lessons from the past as they create the future with PCNs, we are making them available for only £9.99, a discount of over 60%, for as long as stocks last.  Click here for your copy.  The fastest way to success is always to learn first from those who have gone before you.

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