The Inquiry into the Future of General Practice

The Commons Health and Social Care Committee has announced a review into the future of general practice.  What does this mean, why would they do this, and what are the implications for the service?

The Health and Social Care Committee is a cross party committee charged with overseeing the operations of the Department of Health and Social Care and its associated agencies and public bodies (including NHS England).  It essentially has a scrutiny role.

The Committee chooses its own subjects of inquiry, which it then undertakes by reviewing written and oral evidence.  Once complete, the findings of the inquiry are reported by the Committee to the House of Commons.  The government then has 60 days to reply to the Committee’s recommendations.  The government does not have to accept them, e.g. the Environmental Audit Committee inquiry into disposable packaging recommended a 25p “latte levy” on disposable coffee cups; but the government rejected it, preferring for coffee shops to incentivise customers by offering discounts for the use of reusable cups.  However the cross party nature of the Committee, designed to build consensus across parliament, means its recommendations do still exert considerable influence.

This committee on the 16th November launched an inquiry into the future of general practice.  Its headline focus is to examine both the challenges facing general practice over the next 5 years, and the biggest and current barriers to access to general practice.  The committee is actively seeking evidence from anyone with expertise in the area (i.e. you, if you are reading this).  The deadline for submissions, which must be no longer than 3,000 words, is Tuesday 14th December.

It is one of 9 current inquiries the Health and Social Care Committee either has underway or that are complete and are awaiting a government response.  The others are workforce burnout, lessons learnt from coronavirus, children and young people’s mental health, treatment of autistic people and individuals with learning disabilities, supporting those with dementia and their carers, cancer services, clearing the backlog from the pandemic, and NHS litigation reform.

The inquiry into general practice will cover a range of issues (you can find the full terms of reference here), but it includes regional variation in general practice, general practice workload, and the partnership model of general practice.  The specific question in relation to the latter of these points is, “Is the traditional model of general practice sustainable given recruitment challenges, the prioritisation of integrated care, and the shift towards salaried GP posts?”.   There is also a question about PCNs, “Has the development of PCNs improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?”.

What can we make of the announcement of the inquiry into the future of general practice?

The first point to note is the timing of the announcement.  It has come at a point where there has been considerable media and public attention to the challenges around access to general practice, and is also hot on the heels of the announcement of a ballot for industrial action of GPs by the BMA in response to NHS England’s recent publication on improving access and support for general practice.  It does not seem unreasonable for this to have been picked up as a point of concern by the Committee at this point in time.

The second point to note is that the Chair of the Health and Social Care Committee is Jeremy Hunt.  Jeremy Hunt appears to be enjoying his role as a backbench GP, able to chair this committee from a position of considerable knowledge, particularly in terms of how he can make life as uncomfortable as possible for the government.  His own response to the NHS England document was that it “won’t turn the tide” for GPs, and this seems to be reflected in some of the wording of the terms of reference, e.g. “to what extent does the government’s and NHS England’s plan for improving access for patients and supporting general practice address these barriers” (to access to general practice) when it is already clear to everyone that it does not.

There will be the more cynical who assume this is a back door attempt to end the independence of general practice and shift practices into the main body of the NHS, or conversely to privatise things further by shifting all remote and telephone consultations to digital first providers to “reduce pressure” on practices.  And while it does seem odd to want to look at the partnership model of general practice only a few years after the 2019 review by Nigel Watson, the cross party nature of the committee, along with the methodology of collating evidence from as wide a group of experts as possible, does make this seem unlikely.

Whilst it is hard for anyone in general practice to trust anything led by Jeremy Hunt, my sense is the best course of action would be for as many of those working in general practice as possible to give evidence and provide their views on the questions asked and what is needed going forward.  It feels like a genuine chance to be heard, and is a welcome change from the recent policy directives received from NHS England which have had little or no consultation at all.

3 Reasons to be Concerned about the Newly Announced Review of PCNs

The NHS announced last week that  they would be undertaking a review of primary care networks and how they will “work with partners across newly formed integrated care systems to meet the health needs of people in their local areas”.  The review will report by March 2022, ahead of ICSs going live as statutory bodies.  Whilst it might all appear very anodyne on the surface, it does set alarm bells ringing.

There are three reasons for concern.

  1. The perceived need for greater national direction

What the announcement of the review signals is that NHS England, in what is now customary NHS England style, is seeking greater control over PCNs and how they operate.  The initial language used around PCNs was that they how they operated was for local determination by local practices to best meet the needs of local communities.

That, however, now appears to be going out of the window.  NHS England clearly wants to set more guidance and rules on PCNs and how they work.  The contractual constraints of PCNs are already suffocating for many, and so it is hard to see how extra national directions will be helpful.

What we have with this review is a signal that someone somewhere high up is not happy with how PCNs are progressing, and has put this review in place to change where they are headed.  This review has also been announced hot on the heels of the BMA motion for industrial action and mass resignations from PCNs.  This may be unrelated, but it does lead on to my second concern.

  1. It signals a shift in ownership of PCNs away from practices

If you read the announcement from NHS England you will notice it has a very clear focus on joint working.  It talks about how PCNs “will work with partners”, how they can “drive more integrated primary, community and social care services at a local level”, how they can “bring partners together at a local level” etc etc (it carries on like this throughout).

If you recall when PCNs were first announced there was quite a number of references made to how PCN Boards would be expanded over time to be more than simply the member practices.  Whilst some PCNs have widened their PCN Board membership, most have not.  Given the language in this announcement it would be astonishing if the recommendations made were not about a shift of PCN ownership away from practices and towards a much wider ownership.

How far-fetched is it to suggest that this report will end up “recommending” a place for councils, community trusts (and no doubt others) on PCN Boards? Maybe a direct accountability into place-based partnerships will be imposed on them.  Whatever comes, it is hard to envisage a positive outcome of this review for practices.

  1. It further widens the gap between PCNs and the sustainability of general practice

At a critical point in time, just over half way through the 5 year GP contract that introduced PCNs, when general practice has reached such a desperate place that it is prepared to consider strike action, this review is announced.  In the announcement general practice or GP practices receive only one mention, and that is about the need to improve partnership working between GP practices and other organisations.

This report will not be looking at how PCNs can better support the sustainability of GP practices, despite the majority of the additional funding for general practice coming via PCNs.  It is hard not to see the announcement of this report as part of NHS England’s response to the GPC’s threat of industrial action, and if it is it spells more bad news for general practice.

I am not generally a pessimist or a conspiracy theorist, but everything about this report sets alarm bells ringing.  Time will tell whether these are unfounded concerns, or whether it is the first signal of yet more challenges to come for general practice.

Is General Practice Making the Most of the Opportunity of PCNs?

It is a difficult time for general practice right now. The pressures of workforce and workload are higher than ever, exacerbated by the media and their impact on patient expectations and overall morale.  How can general practice move forward?  How can it shift from the place that it is now into a more sustainable future?

In 2016 the GP Forward View, a 5 year “rescue package” for general practice, announced an extra £2.4bn for general practice by 2021.  This was then somewhat usurped in 2019 with the new 5 year GP contract that announced an additional £2.8bn for general practice by 2024.

What we have known for a while is that more resources on its own are never going to be enough for general practice.  We don’t feel £2.4bn better off than five years ago.  The reason for this is the growth in resources will never be able to keep up with the growth in patient demand and expectations.  There need to be changes alongside the resources.  These changes need to be in how we manage demand and how we organise ourselves.

Here we get into problems.  No one really likes change.  Look at how certain sections of the public and the media have reacted to changes to the management of demand in general practice where only those who actually need to be seen (as opposed to those who want to be) are seen face to face.  Whether the government likes it or not we will end up there, but it helpfully reinforces the point that no one likes change.

When you examine what options are available for changes in terms of how general practice organises itself (which we did in our 2016 book) they are broadly around staffing, operating at scale, using technology and working in partnership with other organisations.

This is where PCNs come in.  What stands out for me about PCNs is that they offer an opportunity for practices to be able to make virtually all of these changes, and to be able to do so in a way that protects the independent contractor model.  Prior to PCNs it was all about mergers and super practices, but what PCNs do is provide a construct that allows practices to access the benefits of scale while at the same time protecting their own individual identities.

But delivering the potential benefits does not happen by itself, or as a function of signing up to the PCN DES.  It requires practices within a PCN to commit to using the PCN construct to drive change in the way the practices operate to realise the benefits.  Change does not become easy because you call it a PCN.  It remains difficult, but what PCNs provide is a framework for practices to use if they choose to do so (in addition to providing a huge source of resources – £1.8bn of the additional £2.8bn announced in 2019 is coming via PCNs).

I have no idea whether this was the original idea behind PCNs.  I suspect it wasn’t.  Certainly the contractual nature of PCNs, the tick box style of the IIF, the push to recruit more and more new roles with hardly any support for transformation alongside these roles, and the continual attempts by the system to hijack the PCN agenda are not conducive to practice transformation.  But at their core PCNs do provide practices with the chance to broaden their staffing model to reduce the pressure on the GPs and to build relationships with other practices and other organisations to create shared service models that work better for everyone.

However, at present it feels like PCNs are an opportunity for general practice that is not really being grasped.  Many practices choose to keep PCNs at arm’s length.  The BMA is trying to use PCNs as a mechanism for pressuring government and NHSE.  Others want to use PCNs for their own ends.  But PCNs are a huge, well-resourced opportunity to make change that can be a huge force for good and for creating a positive future for practices.  Practices just need to choose to take it.

Should PCNs be Political Footballs?

Two weeks ago the BMA reported that it had rejected what it terms “the government’s rescue package” and that it was to take a ballot with the profession on industrial action.

The specific motion passed by the GP Committee contained two clauses directly pertaining to PCNs. It:

ii. calls on all practices in England to pause all ARRS recruitment and to disengage from the demands of the PCN DES
iv. calls on all practices in England to submit undated resignations from the PCN DES to be held by their LMCs, only to be issued on the condition that submissions by a critical mass of more than 50% of eligible practices is received

What does this mean for PCNs?  There are effectively three requests being made of practices in relation to PCNs.  The first is to pause ARRS recruitment.  Unfortunately ARRS recruitment is the one part of the PCN DES that many practices consider to be value adding.  Whilst there are some whose primary concern is the clinical supervision, line management and estates challenges these roles can create, increasingly practices are able to realise the benefits of these additional staff on their workload and outcomes for their populations.

It is hard to understand how sending a message to practices and PCNs to stop recruitment into these roles, the one thing that is helping with overall workload, is helpful in the current context.  Do we think that collective pausing of recruitment for a few weeks or months will influence the government/NHS England?  The downside of the suggestion seems far more detrimental than any potential upside.

The second is the call for practices to disengage from the demands of the PCN DES.  There is an anger amongst many that the delivery expectations on PCNs have been ramped up so steeply from October 1st.  The number of IIF indicators (the ‘PCN QOF’) has gone up from 6 to 19 for the last six months of the year, along with a requirement to deliver against two additional DES specifications (health inequalities and CVD prevention and diagnosis).  Disengaging will, however, potentially cost the practices of an average PCN £120k (what they could earn through delivery of the IIF indicators, which are also linked to the delivery of the two specifications).

The third is the submission of undated resignations from the PCN DES by practices. This suggests that the reason practices participate in the PCN DES is because they want to support the government’s/NHS’s desire for PCNs to exist.  In reality there are two reasons.  The first is that PCNs make sense financially for practices, and the second is that practices believe that by working together as a PCN they can improve outcomes for patients.  While the initial decision to sign up was probably more for the former reason, as time has gone by more practices believe they can make a difference through their PCN.

The request, then, is for practices to sacrifice the benefits they receive and believe can be achieved for their patients in order to derail the wider national plan in relation to PCNs, to build influence in the debate on the issues of concern (i.e. the failure to address the crisis in general practice, the recently published plan around access, the GP earnings declarations, and for GPs to oversee the Covid vaccination exemption process).

I understand the desire for greater negotiating power.  The cost, however, falls on PCNs themselves.  While PCNs have been working hard to build trust across their practices, to create ways of working that benefit all, and to make a difference both to practice sustainability and patient outcomes, the effect of something like this is to set the whole thing back.  It makes it easier for the practices that have never really engaged to not do so, and makes it even more difficult for those who have been working hard to realise the benefits of joint working, because now the spectre of mass resignation can sit as a rationale for inaction.

So is it worth it?  Is the threat around PCNs worth the problems this causes to practices?  The Guardian reported that the BMA had won “significant concessions” from NHS England following its threat of potential industrial action.  These included the plan to publish ‘league tables’ – showing what proportion of appointments were in person – had been abandoned, along with specific targets.  However, the organisation seemingly responsible for setting policy in relation to general practice, the Daily Mail, reported that the Department of Health had moved quickly to insist it had made no concession to doctors’ unions, and that it would press ahead with measures to publish surgery-level data on face-to-face appointments.

Time will tell how this will all play out.  I fully support the push back by general practice to the NHS England paper on access, which was the NHS operating at its very worst.  However, I worry that not enough thought has been put into the consequences of conflating PCNs into a dispute that is not actually about PCNs.  Doing so is effectively self-harming for the service, and in particular it has left those in PCN Clinical Director roles, who are arguably doing the most for general practice right now, in a very difficult position indeed.

GUEST BLOG: Dr Rachel Morris – 3 Conversations You Should Be Having With Your Overwhelmed Teams Right Now

Many of our team members in Primary Care are feeling battered and bruised by the tone and content of what’s coming out from on high, and everything going on in the media. As a leader you may feel frustrated and angry yourself, and you may be wondering just what you can do to help everyone keep on going through these really tricky times.

There are three key questions which will help you and your team to take stock of what you can do about the situation, work out what you should be prioritising and reduce some of the stress and anger about what’s going on.

 

What can I control?

The first question is all about what is in your power to change, and what’s not.

In any of life’s challenges, there are things which we worry about which we simply can’t do anything about (for example, rising COVID rates, government policy, the national shortage of GPs). Dwelling on these things is a waste of precious time and effort as there is literally NOTHING that you can do to change them.

A far more productive way to spend your time and mental energy is to ask yourself ‘what is in my control right now?’. A simple way of doing this is to do the ‘Zone of Power’ exercise.

Get a sheet of A4 paper, draw a circle – this is your zone of power. Outside the circle list all those things you are not in control of, and inside the circle list all the things which you ARE in control of, and the options and choices which you have. You may not like all of these options and choices and you may feel frustrated about the consequences of some of these choices, but you will feel more powerful and productive by focussing on what you CAN do rather than what you can’t.

The key to this exercise is learning to ACCEPT the things you can’t change and find the COURAGE to change the things you can (this will also help you with the WISDOM to know the difference – sound familiar?!).

Use this question with your team members whenever any of you feel stuck, to work out what your next actions could be.

 

Where is your focus?

The second question helps teams get super clear about what your priorities should be right now.

Many teams in primary care are feeling overwhelmed and exhausted. There are too many things to do and not enough time or staff to do them. But do you know exactly what these things are? Have you had a conversation about what you should be prioritising as a team, as a practice, as a PCN?

So often, we see team members with different priorities going in different directions which causes confusion and overwhelm as no one really knows which is the most important priority, and what they can drop for now. Without this conversation, the stuff that’s urgent will always crowd out the stuff that’s really important but perhaps not urgent – yet, such as team development, sorting out workflows, delegation and staff training.

Getting clear on what three things you will be focussing on as a team in the next week, month and year will help reduce overwhelm, create some mental headspace, and make sure you’re all laser focussed on the same things.

 

What story are you telling?

As patient demand and expectation seem to grow every week and negative stories in the media threaten to kill our morale stone dead, it’s helpful to ask yourself ‘What is the story in my head’ about the things that are bothering you.

When patients are rude and demanding, do we tell ourselves that’s because they are completely unreasonable, that they all hate us and that we’re doing a terrible job? Or do we recognise the truth – that patients may be frightened and worried about themselves (after all, we are going through an incredibly traumatic time as a planet), they may be frustrated that they can’t get exactly what they want instantly (in a world of Amazon Prime and Netflix).

Do we tell ourselves that we are failing and not good enough? Or that Primary Care is doing an AMAZING job in the face of huge challenges, and that we are doing our absolute best through difficult times?

Are we telling ourselves that it’s us vs “them”. Or that we are all actually on the same side, wanting a properly funded, safe and efficient primary care service in which staff AND patients are thriving?

Are we telling ourselves that we ‘have’ to do it all, can’t take any time out or that saying ‘no’ makes us a bad person? Or are we recognising the truth that it’s only by putting our own oxygen mask on first, recognising our limits, and taking time to rest and recharge that we will do our best work?

The stories we tell ourselves create feelings which lead to actions. The negative stories we tell can only lead to stress, disillusionment and often keep us stuck and frustrated. By re-framing what we choose to believe (but not denying the reality of the difficulties) we can start to change our feelings and actions and reduce the stress and levels of burnout we experience.

These are simple questions, but they are not easy. They require a degree of self-examination and recognition of some difficult truths BUT if you start to ask them with an open mind, kindness and a large helping of self-compassion they may just help you and your team make better decisions, take control of your workload, and start to enjoy what you do again.

Our Resilient Team Academy online membership for leaders in health and social care provides conversations canvasses, coaching demos, video training modules, bite size team building videos and deep dive live webinars to help leaders and managers have these important conversations and support their teams care for resilience, wellbeing and productivity. Doors to the RTA are open right now and we have discounted packages for Ockham Healthcare subscribers, and packages for PCNs and other organisations. Find out more here or get in contact with Ben (ben@ockham.healthcare).

You may also be interested in watching a recording of a recent webinar that Ben and I did, ‘How to support your team through the new ways of working in primary care, without burning out yourself.’ You can find it here.

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