How likely is it that PCNs will go?

Many PCNs are finding themselves increasingly hamstrung by the lack of certainty as to what is coming next.  We know the 5 years of the PCN DES comes to an end in March next year, and so the question that many have is whether it is worth investing time and effort into the PCN given the chance that things may all change again in a little over 9 months’ time.

Life for PCN Clinical Directors, managers and leaders is difficult enough, without having this additional uncertainty to contend with.  But how real is this uncertainty, and how likely is it that PCNs will be replaced by something new in just a few months’ time?

The first place to start is the wider NHS environment.  The NHS has entered the new world of Integrated Care Systems (ICSs).  It is fair to say that even those working in these new bodies are finding it hard to fully get their heads round what they are supposed to be doing, but the government’s response to the Hewitt report on ICSs suggests that they are going to remain the overall direction of travel for the NHS into the foreseeable future.

ICSs are premised on all of the different parts of the NHS system working together in partnership to improve the delivery of care for patients. General practice is one of these system parts.  Historically the system has found it impossible to partner with the 7000+ GP practices across the country, which was the main driver behind the introduction of what is now 1250 PCNs around neighbourhood areas.

Given the ongoing push for partnership working across the NHS, it therefore seems highly unlikely that there will be a rowing back from the joint working between practices that PCNs have created.  While this will undoubtedly be much to the disappointment of the many GPs and practices who dislike the requirement to work with other practices through PCNs, this unpopularity will not result in a national reversion to practices as the primary unit for the delivery of resources into general practice.

Instead what we will most likely see is a move to strengthen the joint working between practices across neighbourhood areas that has been developed over the last 5 years by PCNs.

The question is whether this will remain as PCNs per se, or whether these will be changed into something else.  The biggest clue we have as to that question is in the Fuller Report, which states that PCNs are to “evolve into” integrated neighbourhood teams.  It describes these in this way,

This is usually most powerful in neighbourhoods of 30-50,000, where teams from across primary care networks (PCNs), wider primary care providers, secondary care teams, social care teams, and domiciliary and care staff can work together to share resources and information and form multidisciplinary teams (MDTs) dedicated to improving the health and wellbeing of a local community and tackling health inequalities.” Fuller report p6.

The Fuller report was published over a year ago, and yet still now no one seems any the wiser as to what an integrated neighbourhood team actually is.  While many ICSs have groups looking at this, the timescale set in the report that these integrated neighbourhood teams would up and running in the “Core20PLUS5 most deprived areas by April 2023” has clearly been missed.

The key question appears to be whether an integrated neighbourhood team replaces the PCN, i.e. once there is an integrated neighbourhood team there is no longer a PCN, or whether the PCN represents the group of GP practices that are participating as a group in the local integrated neighbourhood team, which has a much wider group of participants than the PCN.  This latter option appears to be the one being adopted by those places that do claim already to have integrated neighbourhood teams (e.g. Suffolk).

So it would seem that the most likely outcome is that PCNs remain.  Even Labour’s health policy, despite all the noise they have made around nationalising general practice, is to create a “Neighbourhood Health Service”, which very much looks like it has PCNs at the centre.  In fact, given the current policy environment, it is hard right now to envision a future in which there is not something PCN-shaped that continues to be the conduit for the majority of additional resources coming into general practice.

While none of us know for sure what the future holds, it does seem a safe bet that NHS England and the government will want to build on the progress they have made through PCNs beyond March 2024.  There is a chance that the name will change (it is still the NHS after all), but it seem extremely unlikely that the scale of working will alter as there have been no pointers in any other direction.  The pressure for the PCN unit to build more effective partnerships with system partners will undoubtedly grow, but the core unit of the group of practices as a PCN seems destined to remain.

Given this, the most sensible course for practices right now is to continue to invest in the PCN, and ensure that the collection of practices that form the PCN are as solid and secure as possible so that they are as ready as they can be for whatever the evolution is that they will have to collectively face next year.

What Happens After We Make a Change?

Many practices are in the process of making changes to the way their access systems work right now, in response to the contractual changes imposed upon them this year.  But what happens after a change has been made?  What doe we need to do to make the most of the changes we are making?

Once a change has been made the worst thing you can do is file it in the “finished” folder and move on to whatever is next.  Nicola Bateman carried out research following the various stages of an improvement activity and considered the different outcomes in terms of the sustainability at each phase.  She found that any initial gains can be lost, and that there are three actions that determine longer term success, post the initial implementation of a change.

The first action is to stick with the new way of working.  It is quite common for  a new way of working to be introduced, but then when problems occur, or resistance from certain individuals becomes too high, the new system is abandoned and things revert to the way they were previously.  Any gains initially achieved are quickly lost.

The second important action is to close out any technical issues.  So for example when we change our access systems the messages on the telephone system may need tweaking until they are right, or the allocation of slots to different clinicians may need to be adapted so that it matches real demand, or the training and support the reception staff need to be effective as care navigators may need to be updated so that the best possible use of the available capacity can be made (etc).

However, we often introduce a change and do not make time to resolve the technical issues that inevitably occur when we are trying something for the first time.  This limits any improvement we will see from a change to that which is achieved at the point of the initial implementation.  It is hard making changes, so when we invest time in doing so we need to make the most we can out of the new system.  It is worth closing out any technical issues to maximise the overall benefit.

The third action is to work on continuously improving the new system.  While the second action is about closing out any issues preventing the newly identified way of working from being as effective as it can be, this action is about finding new changes that can make it work even better.  So, for example, if we take the case of St Lawrence Surgery in Worthing they found that having a clinician physically based alongside the patient services team undertaking the care navigation made the system work even better for them.

What do we need to do to make sure that continuous improvement takes place?  The research identifies a number of specific enablers.

The first is making sure the whole team is bought in to and understand the changes that are being made.  Taking time to work through the resistance (that there will inevitably be) from certain quarters, and ensuring that everyone, especially those not directly involved in the design of the change, is fully aware of the new ways of working is vital.

The second enabler is making sure the change is part of an overall strategic direction for the practice.  Where does the practice ultimately want to get to with access?  This prevents the change being a one-off reaction to a contractual change, and makes it a step towards wherever it is the practice wants to get to.

The final enabler is making sure that all of the partners in the practice are bought into and involved in the change, that they visibly support it, and that there is a clearly identified lead for coordinating both this change and the ongoing improvement work.  This level of focus from the top creates clarity across the practice and helps build a culture of continuous improvement.

Ultimately, it is often not the change itself that determines the overall level of improvement that is achieved, but the way the change is made.

How the PCN Practice Relationship Has to Change

The focus on access in this year’s contract mean that the relationship between PCNs and their member practices need to change.  The PCN leadership needs to take on a much more supportive role while practices must become more active in shaping the work of the PCN.

Things are different this year.  Despite the government’s claims that it has simply imposed year 5 of the existing contract, the reality is it hasn’t.  They took legislation through parliament to be able to change the core GP contract, which placed a new requirement on practices to respond to contacts made by patients on the day the contact is made (full details here).

What has then happened is that PCN funding has been used to support the change.  The IIF has largely been scrapped, being reduced to just five indicators worth £59 million, with the remaining IIF-committed funding of £246m for 2023/24 now becoming a Capacity and Access Payment.

‘National Capacity and Access Support Payment: 70% of funding (£172.2m) will be unconditionally paid to PCNs, proportionally to their Adjusted Population, in 12 equal payments over the 2023/24 financial year’ (PCN DES).

This is not really unconditional money.  It is money to enable practices to make the changes they need to become compliant with the new terms of the contract (without that ever having explicitly been said).

There are some explicit overlaps, e.g. the contractual requirement for practices to use digital telephony and its inclusion within the PCN access improvement plan.  Indeed, the PCN plan has to, “set out the current position across the PCN, by each practice in the PCN, according to the table below” according to the NHSE guidance.  The capacity and access work of the PCN is (intentionally) inextricably linked to the introduction of the imposed contract changes on individual practices.

The payment of the remainder of the IIF money, i.e. the other 30% of the national capacity and access support payment, is based on the PCN demonstrating improvements made by its practices in this area, e.g. have all the practices scheduled a date to shift to digital telephony, are all the practices accurately recording appointments.

This represents a pretty fundamental shift.  In the past the dynamic between PCNs and practices was essentially one where the PCN led the delivery of work, and this work was supported by the member practices.  For example the PCN had to ensure that all the care homes were receiving regular ward rounds, and each of the practices had to play their part.  Or the PCN had to ensure the IIF indicators were being delivered and each practice had to play its part.  But each time the responsibility lay with the PCN, and the practices had very much a support role.

This feels different.  For one thing, how on the day demand is managed during core hours is very much core contractual work for practices, which up until now had very much been none-of-the-PCN’s-business.  All of a sudden how practices are run has become of mutual concern.  And the funding to enable practices to deliver their (albeit new) contractual requirements is being given to the PCN (via the capacity and access payment), when previously core contractual funding had always come directly to the practices.

For this work, it is hard to see how the common PCN-led, practice-supported model of delivery is going to be effective.  PCNs can’t for example be telling practices how to run their on the day demand, or demanding project plans from each of their practices.

Instead the PCN delivery model needs to change, and become one that is more practice-led and PCN-supported.  There can be rich learning across practices within a PCN as to how they do things and what works and what does not.  There can be mutual support from practices who have introduced digital telephony sharing the opportunities and pitfalls with those doing it for the first time.  There can be practice-led conversations as to how ARRS staff need to be deployed to enable the right range of care navigation opportunities for them to be able to meet their contractual responsibilities, which the PCN can support.

This year’s changes mean the relationship between PCNs and practices needs to evolve, with the PCN leadership taking on a much more supportive and enabling role, creating a sharing and learning environment, while practices become much more active in designing and shaping the specific changes that need to be made.

Is it Time to Make our Practices PCN-sized?

As the direction of travel looks more and more like it is PCN-shaped and geared towards general practice at bigger scale, should practices within a PCN be considering whether remaining as separate entities is really the best course of action?

There are some heavy hints in the Delivery Plan for Recovering Access to Primary Care document that whatever comes next will be a further push to at-scale working in general practice, in particular the rather unambiguous, “Integrating primary care requires general practice to operate at a larger scale either as part of PCNs or at place level” (p41).

Whatever comes next, don’t expect it to be an end to PCNs and a reversion to receiving funding directly at a practice level.  What is clear is that the wider NHS integrated care agenda is seeking to create bigger, more partnership-friendly units of general practice, and this is not going to change simply because PCNs are not hugely popular with core general practice.

We don’t know the detail of what is coming next.  I don’t think anybody does, even NHS England.  But I do think there are some principles that we can be relatively sure of, and these are that whatever changes are agreed (or imposed) they will be supporting at-scale general practice, more local commissioning of general practice (i.e. less via the national contract), and enabling easier partnerships between general practice and other local providers.

What can practices do now?  Is there anything, because the uncertainty as to what is coming next can be stifling, and indeed for many is creating a reluctance to take any action at all.

I think this is a mistake.  What we have is 10 months of certainty, as we know exactly what is in this year’s contract.  By now we know what we are doing with PCNs (by and large), and so there is almost a sense of this year being the calm before the (next) storm. To me this represents the perfect opportunity to make any big or strategic changes that the practice is considering.

What would these changes be?  Well, the most obvious change is for practices within a PCN to merge and become a single practice.  At present the PCN funding, and ARRS staffing, is separate from practice funding and staffing.  Except it is not in those practices that are single practice PCNs.  In those practices what happens is the PCN requirements simply become another part of the practice’s contractual requirements, and the practice is able to use all of the resources (funding and staffing) as flexibly as it wishes to meet the totality of the requirements.

You can listen in to the Swan practice/PCN explaining how it works for them as a single practice PCN here.  It was no accident that the case study used on p41 of the Access Recovery Plan discussing the future of general practice is that of the Foundry – another single practice PCN.

While I understand the challenges that merging practices creates, and the resistance that many GPs have to the loss of individual autonomy that comes with it, I am not convinced that practices can continue to be sustainable whilst PCN funding and core practice funding remain separate.  Bringing the two together feels like a smart move because of how it enables a longer term sustainability for the practice.  It certainly seems preferable to that funding (PCN, or whatever its successor is) being held by an NHS provider, and the practice constantly having to fight to access it (which seems like one of the alternatives being considered).

It is true we do not know what the future holds, and so there is always an element of risk.  But doing nothing also contains risks, and given that we know the funding flow is much more likely to be PCN-shaped than practice-shaped, making our practices PCN-shaped while we still have the chance feels like an option we should be giving much more time to considering.

What do the Changes to GMS Contract Symbolise?

This year the government took the unusual step of laying legislation before parliament to change the core GMS contract.  Why would they do this, and what does it mean for general practice?

In 2019 a 5 year deal was agreed between the GPC and NHS England.  Pressures on the service, in large part brought about by inflation running at over 10%, meant the GPC has tried to renegotiate this contract (without success) in the last 2 years.  The result has been the negotiated terms of the 2019 agreement have been imposed on the service without agreement.

But this year that is not the only thing that happened.  The publication of the core GMS contract was delayed, and it turns out this was because the government laid legislation before parliament to make changes to the core GMS contract that came into effect on the 15 May.

These changes are in relation to access, and stipulate how practices are to respond to contacts made by their patients.  The GPC have summarised the changes here if you have not seen them.

Why would the government choose to take the unusual step of putting legislation before parliament to change the core GMS contract?

We can only speculate as to the motivation, but it may have been because the only way of the government directing general practice is through the contract.  The GPC had refused to negotiate any changes, but (it turns out) it is within the government’s gift to use parliamentary legislation to make any changes it wants to the core contract.

Of course, changes to the core contract are only meaningful if they are enforced by local commissioners (i.e. the ICBs).  The way that contract management takes place does vary around the country, but generally commissioners try and partner with general practice rather than use heavy handed contract management techniques.  An important question is whether this legislative change will in turn lead to a much heavier handed contract management approach by local ICBs.  Only time will tell if this is the case, but more local disputes seem inevitable.

Meanwhile, the legislative change has already (unsurprisingly) provoked a backlash from the profession.  The GPC response has been to reassert their safe working guidance, which is to move to 15 minute appointments, undertake a maximum of 25 patient contacts per day, and to introduce a waiting list system for appointments.   It says, “any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or urgent treatment centres. This is permitted within the contract which says that patients should be offered assessment of need or be signposted to an appropriate service”.

As ever, the combative BBO LMC have been quick out of the gates in offering guidance to their practices.  You can find it here, and it is unsurprisingly defensive in light of the contractual nature of the change being imposed.   They believe the contractual changes, “will likely result in practices diverting extremely large numbers of patients to 111 and A&E for fear of being held in contract breach, due to the unclear meaning of this clause’.

So it is already clear that imposing contractual changes is not going to lead to service improvement.  This has not happened in the past and it won’t happen now.  It is simply creating bad blood, and a hardening of respective positions, when what the service really needs is support.

Much of the reaction to the Delivery Plan for Recovering Access to General Practice has centred on whether the changes will indeed improve access, and is using that as a marker to determine the value of the paper.  But this misses the fundamental problem that creating a focus on access into general practice deepens the discord between what the government consider the purpose of general practice to be (easy access for patients) and what the profession considers its own purpose to be.  If you haven’t already please read Jonathan Tomlinson’s recent publication The Future of Primary Care – Threats and Opportunities, in which he surmises, “The value of general practice is health gain achieved, illness prevented and, holding-work – the supportive partnerships that enable patients with long-term conditions, especially mental illnesses, to keep going”, which, he argues, is undermined by the detrimental impact on relationship-based care that the ‘taskification’ of general practice work across a team creates.

It also sidesteps (ignores?) the key issue of the pressure created by the funding cuts to the service because of the government’s refusal to at least match inflation.  The document itself is clearly not (as it is sometimes referred to) a recovery plan for general practice.  It is explicitly a delivery plan for recovering access to general practice.  These are two different things, and the concern is that one may be at the expense of the other.

The changes to the GMS contract demonstrate the clear lack of a national relationship between the service and the government, and potentially mark a shift towards a more combative, contract-based style of interaction.  This is not good for general practice.  It will inevitably lead to tensions at a local level.  With the GPC talking about industrial action, and NHS England talking about ‘longer term reform’, my fear is things may get worse before they get better.

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