Primary Care Financial Risks Management: Thoughts on Managing Financial Risk in the New Primary Care Environment

Primary Care in England is changing, with merging GP practices and Primary Care Networks (PCNs) being key to that change – accompanied by the planned extension of the services provided by, coordinated by or funded through the new organisations.  Working with clients on implementing these changes, I am frequently asked what this means in terms of primary care financial risks management, so here are my thoughts on managing financial risk in the new primary care environment.

We are likely to see more and more larger primary care organisations with more services, more finance and more and different staff working in different ways all with a range of new and existing partners. As Integrated Care Systems are introduced that scenario becomes even greater in extent and complexity.

The actions that need to be taken in terms of clinical services and partnership working are for other articles.  Here, I will deal with the Finance governance and administrative issues.  It is important, however, to appreciate that all aspects of planning and management are inextricably linked.

With Opportunities Come Competition

The opportunities for Primary Care to be a driver for improved health and wellbeing in their communities are considerable.  Working with partners across the health sector, local government and the third and private sectors could be a real game changer.  But the NHS will also seek to drive greater effectiveness and efficiency from the new arrangements.  That will, inevitably and rightly, lead to a focus on costs and value for money.  At the same time, major private sector providers are trying to persuade patients and the government that they have or, indeed, are the answer.

My view is a simple one.  I personally value the services provided by Primary Care in the UK and wish it to continue.  But, at the same time, it needs to develop organisationally and in the application of technology.  For instance, there is no reason why existing providers should not apply technology such as virtual consultations while continuing to provide and improve the current high levels of personal service.  High profile organisations are trying to use such technology to take over primary care in the interests of profit.   To compete with them, it is vital that the new arrangements developed by existing providers are managed as well as is possible.

So, this means that the new Primary Care organisations need to:

  • Be well manged, using resources effectively and efficiently;
  • Use technology proactively to improve services and reduce costs
  • Be aware of and manage the significant financial risks that are inherent in larger more complex organisations;
  • Understand fully their costs and income and manage finances proactively; and
  • Be financially accountable to the NHS and partners for the management and disbursement of funds.

Who Bears the Primary Care Financial Risks?

During the past two years I have worked with existing larger scale primary care organisations who have got into trouble simply because their financial management arrangements were not “up to scratch”.

There is anecdotal evidence of some other enterprises providing primary care services facing financial difficulties.  It is worth stating that I also have experience of such organisations that are well managed and financially sound.  It is also relevant that these organisations all have “limited liability” status.

Generally, the organisations running into trouble did not have a clear enough appreciation of the actual financial position until it was too late or, alternatively, the management did not listen to the messages they were receiving.

In General Practice, organisations are usually unlimited liability partnerships meaning that increased risk will tend to lie with the partners personally.   That provides a very good reason for a focus on mitigating the financial risks.  It also provides a motivation for considering organisational forms where that personal risk is mitigated.

Primary Care Financial Risks Management Actions

The actions that need to be taken begin during the formation of the PCNs so that a solid base is established from the start.  These actions include:

  • Having a plan with realistic financial projections (aka a budget) including a:
    • Time profile
    • Cashflow projections
  • Clearly defined management responsibility for each budget heading;
  • Effective budgetary review and control processes; and
  • Financial information systems that provide correct and timely financial information during the year.

The current arrangements in many GP practices where the cash position is monitored by the Practice Manager during the year and the accounts are produced by an accountant some months after the year end will not do.  Having an ongoing, accurate understanding of the costs and income of each area of activity is critical.

That must be much more sophisticated than is currently often the case.  Only by so doing can operational and clinical actions to be taken to keep the organisation on financial track.  That is not to say that clinical decision making should be finance driven but that it should be done in the full knowledge of the financial implications.

Use of Modern Financial Systems

Modern financial systems are available (often used in GP practices).  These can enable much easier and more accurate generation of information.  But, usually, they are not used in that way.  That must change.

The generation of that information enables control that assists in mitigating the risks that are faced.  That information will also provide a basis for accountability for the application of NHS and other resources. General Practice and PCNs are expected to drive population health services and be enablers for change. Clear and accountable financial management and opportunity development must service that change.

Managing Financial Risks in the New Primary Care Environment

For more detailed information and advice on managing financial risks within the changing primary care environment, please do not hesitate to contact At Scale today.

Working with a coach, is it really for me?

So, we have all heard about coaching, both to individuals and organisations, but there’s a huge gap between hearing about them and recognising what they can offer. The NHS Ten Year Plan (click for a downloadable PDF) provides insight to both effective resources and the need for operational and innovative leadership to drive collaboration. You may well ask how can your coach help to achieve this?

Thinking from outside the organisation.

We have all heard of and indeed often do ‘think outside the box’ but is this enough, where do we find the time to do this and where do we start? The NHS is a powerful beast, but sometimes you can be so close to whatever you are doing, you lose clarity. We are knowledge rich, time poor and your coach can think outside the organisation for you. While the NHS has its structure and its way of doing things, its changing, and the current pace of change suggests it will maintain that momentum. A coach can provide clarity, but can also provide useful insight, particularly if you hire one that has had experience both inside, and outside the service. They can make it easier to see things from a distance and make better decisions because of it. You’ll get a whole new perspective as a result.

A source of encouragement

Working in the NHS is a challenge, no matter how far along the road you are. You may not always have a source of support to turn to. A coach can provide the source you need. Regular meetings will also ensure you have that input to look forward to. Look on them as a critical friend with only your best interests at heart.

A confidential sounding board

When you hire a coach, every session between the two of you will be completely confidential. This means you can discuss whatever you wish. The coach has no direct connection to your organisation, which means they can devote their attention entirely to your needs. You can discuss your role, the way you approach the organisation and day-to-day tasks, and anything else that is relevant or important at the time. Your coach will be able to help you by acting as a sounding board – giving you the confidence to deliver better results.

Finding solutions to problems

No matter what organisation you are in, you’ll encounter problems along the way. That’s pretty much a given. What can change is the way you tackle them. Sometimes you may struggle to find an appropriate solution. You can sleep on a problem, brainstorm solutions and rely on your experience to find the right path forward. Yet you may still come up against the proverbial brick wall. A coach may be able to help you knock that wall down. Since they are removed from the organisation, so to speak, they can help you move towards solutions. They can help you brainstorm in ways you may never have considered before.

Asking the right questions

Even the best manager, CEO or Chair will overlook things in their quest to perform their role to the best of their abilities. It’s so easy to get tunnel vision, leaving you to completely overlook elements that might be obvious to others. A good coach can ask the right questions – questions that will steer you towards a better performance on a continued basis.

A greater degree of efficiency

You may find your relationship with a coach causes you to become more efficient too. It’s easy to think a monthly meeting with a coach takes you away from your work. Yet the time you spend together will likely be extremely fruitful. You will probably find you come away from that meeting with plenty of ideas and ways to take your department or organisation forward. In short, some time spent with a coach might just be one of the best things you do.

Get in touch

If you would like to know more about how we can help you, please email us at info@at-scale.co.uk. You can also contact Alan directly at alan.ball@at-scale.co.uk.

Alan Ball is a Director of At-Scale and has a career both inside and outside of the NHS, having been a NED for a Hospital, and a GP Federation, and latterly the Managing Partner of Octagon Medical Practice. Alan holds an MSc Masters Degree in Psychology & Coaching from the University of East London, and is a member of both the ICF (International Coaching Federation) and the AC (Association of Coaching)

Why Should I Collaborate?

Collaboration is a much-used word and is the fallback shortcut for many things that bring general practices together like working at scale, Primary Care Networks and practice mergers. But is there common understanding of what it means, any perception of why it is important and above all, why we should care? This blog tries to answer all three questions.

I often start my blog planning with a quick search of the good old internet just to get my creative juices flowing. Collaboration threw up two interesting positions on this occasion. First, it’s about working with someone to produce something and mentions positive words like co-operation, partnership and joint effort. Nice. But then it mentions traitorous co-operation with an enemy and words like collusion and consorting. Not so nice. I am sure we’ve all come across collaborations that fit into both categories, sometimes for the same project. A factor common to both descriptions is communication. In either case, good communication is more easily achieved with clear and effective leadership in order for your collaboration to be successful. Whatever you may decide success to be.

But why should you care about leading successful collaborations? Well, mostly because your future personal and business success depends on it. As a key asset of the future, you will need to be able to develop and lead successful collaborations. The future is more at scale, more joined up and more, well, collaborative. Why? Because collaborations facilitate access to more resources, can attract more rewards and are able to deliver more benefits. Simple as that.

Understanding what makes for a successful collaboration and proving you can deliver those things makes you “in demand”. Such skills are rare and will be even more in demand in the future. You can make the connection for yourself. That demand applies as much in primary care as it does across other sectors. So maybe think about acquiring those skills now.

Understanding how to bring about collaborations, to motivate and organise participants towards a common purpose and then to bring together different perspectives, is actually a lot harder than it sounds. It needs practical knowledge and application of things like reciprocity, reflection and engagement. Skills and experience we all have I am sure, but how often do we get to practice them? Sometimes collaborations are mandated and we are all compelled to join in. Think Primary Care Networks – general practices really have had to join in or miss out on potential rewards.

The key issue is what should you do right now? Well, I would suggest you may want to get ahead of the game and practice different approaches to hone your collaboration skills. Including understanding the factors that impact on success and learn more about how other people react in collaborations. It’s a fascinating subject area and it will likely take you into better understanding the fear. Yes fear. People fear collaborating and they fear not collaborating (FOMO!). Being part of it or not being part of it. Learn about that.

My partner recently had to endure (her description) an online collaborative forum as part of an OU degree. To say she hated it would not be too strong. She felt it was false and emphasised isolationism rather than her preferred method of sharing, face to face collaboration. But she endured and was amazed at the diversity of views, opinions and angles developed on what was, a tightly defined history question. The joint collateral allowed the whole group to understand the question much better and will, hopefully, lead to better exam results!

So be prepared to widen your opinion and practice of the means and methods that lead to successful collaborations. Your own view may be skewed or biased based on your own experiences. Using the above example, I pondered the learning arising from balancing the isolationism and meetingism (not a real word) we often use to reach an agreed conclusion in primary care.

So how should you start preparing for the future? Well, I would start by securing some good advice from people who have delivered successful collaborations already. Find out what they do and what methods they use. How do they approach setting up potential collaborations and how do they plan activities? Their methods may offer a pointer for what you need to focus on.

Have you got preferred ways of working that don’t always work with those you want to collaborate with? Have you tried doing things differently? Find ways to challenge yourself and to acquire those different skills and you will be on your way.

And make sure you keep up to date with the ever-changing direction of travel. Good collaboration leaders know there is always another one just around the corner.

If you like more information on how we could support your organisation, please get in touch.

top tips for PCNs

Top tips for Primary Care Networks

I was recently asked what advice I’d give to organisations involved in the development of Primary Care Networks (PCNs).  I’ll add in an early disclaimer here that there is no magic bullet!  But what I do hope is that my experience in primary care and commissioning gives a useful and potentially different insight to support those of you currently developing or supporting a PCN, wherever you may be on your journey.

Where are we now?

With less than a week until GP practices must ‘complete and return’ their Primary Care Network (PCN) registrations to sign up to the network contract DES, I think challenging is a good way to describe the process.  Developing new ways of workings, managing change, collaboration and tight timescales are never easy asks.  Couple these with the well reported excessive pressures in day to day general practice and it’s a wonder that PCNs are as progressed as they are.  They do say if you want anything done you should ask a busy person!

So far, my experience of PCNs has been wading through the guidance, getting involved in the discussions with practices about how they are planning to configure their PCN, and liaising with the LMC in their driving of the local arrangements.  I have also been ensuring that system partners are engaged in the conversations and understand the criteria for PCN approval.  There’s a lot of people to bring along in this change.

My advice

But what advice would I give?  Here’s some top tips for each organisation type that I believe is a key player in the development of PCNs:

CCGs and STPs – let the PCNs land, embed and have a chance to be successful before the ask upon them gets too great.

GP federations – Facilitate your members to help them to keep ownership local.  Look for opportunities to bring PCNs together to support wider population coverage and business gain.   Invest in your members to enable them to focus on PCN implementation.

GP practices – Get involved, make sure your voice is heard, don’t have this “done to you or around you”, understand the rules of engagement, recognise that this is a new collective vehicle that needs to collective input to thrive.  The benefits will come from allowing real collaboration to be given a chance to improve workload and workforce issues.

And finally…PCNs – Know the rules, listen and engage, and don’t try to be the answer to everyone’s problems.

If you have any questions about how we could provide support to you through your own PCN journey please get in touch.

Alice Benton is a member of the At Scale team and has almost 18 years NHS commissioning experience, predominantly in primary care.

alice benton

Meet the team – Alice Benton

Over the next few weeks we’ll be introducing you to our At Scale team. To kick start us off, meet the newest member of the At Scale team, Alice Benton.

How did you get into healthcare?

I have almost 18 years NHS commissioning experience, predominantly in primary care. So where did it start? I have a Masters in Human Geography from the University of Southampton – this is where my interest in health and health care started, the impact of place on health and how demography shapes the need that the health system must respond to.

So what tempted you to join the At Scale team?

I’ve joined At Scale as I am keen to work with a team of colleagues that I like and respect. I’m excited about what they have achieved so far and I’m looking forward to using the knowledge and experience I’ve gained in my NHS career to work with health providers and help them to prepare for the new challenges ahead.

The provider landscape is changing, and general practice is having to change quickly to keep up with the increasing demands. There is a need to integrate to ensure scarce resources are used efficiently, and with primary care at the centre, there is a need to get it into the strongest shape possible to enable effective integration. Resilience in general practice is achieved through collaboration and working at scale.

Helping practices to make the decisions to work together and to support them through that process is something I have had experience of as a commissioner and within the NHS. However, there is more work to do and more support that is required than can currently be provided. Approaching this work in a bespoke way for groups of practices and with the structure of the accelerator tools will give practices the additional capacity and support to make the changes they need in order to be fit for the future. The new challenge of getting Primary Care Networks up and running provides a new driver for this change and will mean that all practices are on a journey to collaboration – even if they weren’t quite ready yet!

On a personal level, I have just turned 40, have a 17 month old baby, and need a different pace for work. I have wanted to work in a different way for a long time and the opportunity to join At Scale was something that I couldn’t miss out on. It enables me to continue to work in the field that I have been specialising in for a long time but from a different vantage point. It also has scope to expand into other sectors which I will enjoy learning about and getting involved with.

Can you tell is a little bit about your experience working with Primary Care Networks (PCNs)?

My experience of working with PCNs to date has been all about “landing the PCN map”, being involved in the discussions with practices about how they are planning to configure their PCN, and liaising with the LMC in their driving of the local arrangements.

I have also been ensuring that system partners are engaged in the conversations and understand the criteria for PCN approval. It has been necessary to make sure that voting members of the Primary Care Commissioning Committee are briefed on the contract changes and are up to speed with the changing context in which contractual decisions will be made.

And finally, what are you passionate about?

I’m passionate about primary care and the role it plays at the forefront of the health service. While my wider experience is in general practice commissioning, my passion for strengthening and advocating for primary care extends across the four professions and to a future in which they will be more closely integrated. Continuing to work in an arena that develops and transforms primary care for the ever growing ask on it is something I am excited to be a part of.

PCNs, the myths and the trojan horse

Primary Care Networks (PCNs) in primary care are the hot topic. The notorious aptitude of the NHS for kicking an agenda down the road for a lengthy delay is a well trodden path.  But the speed at which PCNs are being introduced is a real shot across the bows, showing that primary care is about to change in more ways than anyone can guess.

So, I guess the first question is “what makes you the expert?” Being fortunate to have spent the last 35 years running some of the world’s largest businesses, means you get to see trends and signs that are ignored at your peril.

Regardless of your political persuasion, all parties agree that the NHS in its current form is unsustainable. Primary care is about to be” Amazonified” and, as with other sectors, it will creep up and bite you in the backside unless you are prepared.

PCNs at this stage are not complicated. However, general practice has uncertainties about how to structure them, and why wouldn’t there be, you are GPs after all. We have started to see players like Modality offer a national solution which is a smart move and full credit to them. The smarter question is why?

The answer is straightforward. The end game of the PCN will take more and more of the LES and DES Services into the PCN and leave Practices with an unsustainable GMS core service contract. What’s more, the CCG will be able to remove these services if they feel performance is not delivering and, as the PCN is patient centric, it has different sanctions from those of a GMS contract.

So, how should one approach them and what’s the Trojan horse risk?

There have been several questions surrounding the entity that holds the PCN and the obligations upon it. Forget the advice offered by well meaning healthcare professionals, it’s quite simple really. The following are areas that require consideration if you are working in clusters to create your min 30k PCN population:

  1. Allow one of the practices to hold the PCN
    You could allow one of the practices to hold the PCN and create an agreement with the other practices to allow movement of funds and obligations of service.  This is the simplest solution that still requires an agreement to be written but, in my view, you would be foolish in any scenario not to have an agreement between providers. In this solution, the obligations for staff employed under the PCN sit with the holding practice, as do the obligations for performance, so any agreement will need to ensure that these areas are covered.
  1. Create a new entity to hold the PCN
    You could create a new entity to hold the PCN. This is what’s causing a lot of confusion over liabilities and obligations such as VAT. If you do create a new entity, it will have its own full obligations for reporting turnover, profit, taxes etc. This is completely regardless of the structure of the entity. Care also needs to be taken if you create a new entity and it holds the PCN service and not a GMS contract. If services move into a PCN contract and you have to supply them with staff and premises, how will that be recharged and how will you manage the use of staff to ensure your core services are covered? Particularly when online consultations become a compulsory service as will extended access. So a new entity is not a no. It just needs to be understood completely what the FUTURE obligations are under it.  Oh, and for the response on the VAT question, an organisation needs to register for VAT if your sales exceed the threshold in any one year. So depending on how the services in the entity are structured, yes, you may need to register that entity for VAT. There are few exceptions.
  1. Sub-contract your PCN
    The third option is to sub-contract your PCN to someone who “knows” how to do it.  This is the easiest but most dangerous option. However, this is the route many are likely to take because they will see it as an easy option with less hassle. Trust me, the hassle will only just begin when you sign that option over. This is the Trojan horse option in its most dangerous format. What you must do is look at the end game here. Unless there is a political change, PCNs will get more and more service heavy and more and more obligations and deliverables will be put on them. In return, more of the money will flow through them. So, signing over to a national entity is the easy option today but will quickly see your staff being taken and your income diminished, leaving you as a PCN to either merge or close …. The real end game of the NHS here.

Now I know that many of you will see this as alarmist and many others will just pooh pooh it as just not credible. That’s what the high street said of online shopping a decade ago. That’s what the office products industry said a decade ago. You only need to look at those sectors to know life will never be the same again.

Look to the end game, don’t get pushed into coming up with a quick solution because the timeline dictates you have to. There is plenty of time to create any of the two credible entities before jumping out without a parachute into option three.  Talk it through and if you want any support or advice then email me at alan.ball3@nhs.net

Alan Ball is the Managing Partner at Octagon Medical Practice, a Non-Executive Director of ATSCALE and Chairman of Rosia Bay Private Equity fund

Building a Primary Care Network

Are you building a Primary Care Network? Here’s some questions you may want to consider…

GP Federations and PCNs – how they fit into the current primary care landscape?

There was an interesting quote from BMA GP committee chair Dr Richard Vautrey last week on PCNs and the roles of federations. I’m sure many of you will have had your views on this, but certainly within the five year GP contract there wasn’t much reference about the future of federations or how PCNs and federations will coexist.

As you know, PCNs aren’t just the latest trend or buzzword in primary healthcare. They are going to be fundamental in the delivery of primary care services in the future, with a key focus on collaboration and working at scale.

But how to they fit into the current primary care landscape?

I expect (should that be hope?) that there’s going to be more detail and clarity when NHS England and GPC England jointly issue the Network Agreement and 2019/20 Network Contract DES, due by 29 March.

However, Dr Richard Vautrey’s view was very interesting. The interview identified that in many areas, federations would be too big to be regarded as one primary care network but that networks will still need to “work at wider federation level for the delivery of some services where it makes sense to operate at that scale.”

The organisational, legal and operation form of both PCNs and federations is something the ATSCALE team have been working on over the past couple of weeks. We have identified the widest range of legal forms such arrangements could take along with the pros and cons of each. We have developed a PCN Accelerator (PCNA) that allows practices, PCNs, federations and CCGs to identify the issues that need to be tackled when considering the best way to set these organisations up. And to provide assurance to practices and commissioners that there has been due attention paid to both formation and operation.

In the same article, NHS England’s acting director of primary care Dr Nikita Kanani, also spoke about the difference between federations and primary care networks, adding: “Typically a patch would have a CCG, a federation and three or four primary care networks – maybe five. And the federation would be there to help support those networks.”

Our PCN Accelerator takes into account the various strata in primary care including PCNs and federations. Quite simply this new future demonstrates just how much the primary care sector will need to demonstrate new ways of working together. PCNs need to develop swiftly and robustly to respond to the NHS direction of travel, commissioning arrangements and contractual form. This can’t be done in isolation.

As I said in a previous blog, collaboration is key and there is a need for GP practices to be proactive in formation of PCNs, as well as acknowledging the important role of GP federations to support the formation and operation of PCNs.

With the increasing demand placed on CCG’s, federations and GP practices to form PCNs, there has never been a greater need for an experienced team to support your delivery. We only work in primary care and we only work on at scale projects, whether they are collaborations, mergers or PCNs.

If you like more information on how we could support your organisation please get in touch.