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.

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

What is possible in 80 days? Can great things be achieved?

I’m sure many of us are familiar with Jules Verne’s book, in one of it’s many guises, about Phileas Fogg and his attempt to travel Around the world in eighty days. It was clearly quite a productive few weeks, with lots of challenges to overcome and plenty of learning along the way.

So with looming timescales, and just 80 days left until the deadline for the delivery of Primary Care Networks, due to be mobilised on 1 July, what do PCNs need to prioritise?

Setting priorities

For PCNs the next few weeks and months must be all about the development and build of thee networks, in what is a relatively short timescale. And whilst it’s not the same as an around the world trip, it is a significant change in direction for primary healthcare.

We also mustn’t lose sight of the key issues, primarily the formation of PCNs including delivery responsibility, form, structure and future operation. There are certain areas which we can all answer right now, however, some of the challenge PCNs and the wider health sector faces is that some of this guidance is still emerging.

What next?

A lot of work has already been taking place to identify PCNs with lots of discussions already underway. To support this there has been facilitation to help identify ways forward and I’ve been involved, along with the ATSCALE team, to support this with some CCGs, GP federations and GP practices (do drop me a line if this is something we could help you with).

A lot of the work we’ve been involved in has been to facilitate to help identify wants forward, to provide a framework to focus on challenges, and to apply a methodology across CCG areas – ideally led by a federation. In addition to this we’ve been using existing local patterns to outline PCNs, provided mediation and also supported PCN  applications, identifying actions to address issues and risks prior to PCNs being set up. All with an ETA of 1 July 2019.

Some inspiration…

I appreciate my earlier reference was based on Jules Verne’s fictitious journey. However, I wanted to end on a fact I read recently. Inspired by Verne’s novel, in 1889 Nellie Bly decided to try and travel around the world in 80 days for her newspaper, the New York World. She managed to do the journey within 72 days, meeting Verne in Amiens. Her book Around the World in Seventy-Two Days also became a best seller!

Hopefully that’s reassuring news and offers some inspiration and hope, with 80 days left until the deadline for the delivery of Primary Care Networks. And if you have any questions about how we cold provide support to you through your own PCN journey please get in touch.

 

Rachel Edwards is a director at ATSCALE with more than 15 years’ experience working in the public sector and NHS including working on at scale, mergers, collaborations and resilience projects in primary care.

Understanding your next steps to developing Primary Care Networks

In a recent interview with Pulse, NHS England’s acting director of primary care Dr Nikita Kanani has said that Primary Care Networks are an ‘evolution’ because ‘enough of the population is part of a group of practices’.

And whilst that may be the case, the reality is that there is a lot of variation, practices are at very different stages in their journeys towards collaboration, and for some there is still a lack of clarity around expectations.

Under the new five-year contract, details on the arrangements for networks and their service specifications will be released by the end of March – and networks will need to be set up by the end of May. Yes, these are challenging timescales. However, PCNs are a key feature of the new GP contract and importantly, the additional workforce and linked funding is available through these new PCNs.

With the increasing demand placed on CCG’s, federations and GP practices to form PCNs and to deliver at scale, it’s important to identify where you currently are on your journey and to review your current at scale preparations and plans.

There are a number of key questions to consider:

  • How ready are we for at scale working?
  • What are the critical steps we must complete first?
  • Do we understand the cost and resources needed to deliver our at scale entity?
  • What do we need to do with existing partnership agreements?
  • Have we considered our clinical models and systems?
  • Have we considered finances in the right way?
  • Does the work we’ve done so far give us a solid start for our at scale journey?
  • Do we understand the sequence of tasks we have to complete?
  • Have we involved our patients, commissioners and stakeholders sufficiently?
  • How can we manage this project and deliver the day job?

This will start to help you understand and identify your key next steps on your way to working at scale.

There is also support available to help you to deliver PCNs and working at scale. We work with general practices, PCNs, federations and CCGs to provide deliver joined up and at scale primary care services that deliver better outcomes and “more for less”.

We have developed a PCN Readiness tool that reviews your current PCH and at scale preparations and plans. Completing this assessment will deliver a diagnostic to you and if you want, a follow up telephone conversation with one of the ATSCALE team. Have a look on our web site for more details about how you can access the tool and start your planning effectively.

How To Build A PCN

A lot of people in primary care have been asking me about the best way to develop a PCN – Primary Care Networks for those who have been holidaying on the International Space Station or beyond (apply astronauts.nasa.org).

Returning home the other day from the excellent RCGP’s “Creating sustainable General Practice in a disruptive world” national summit, I pondered hearing many questions over the day framed around “how do I build a PCN?” I thought I would break a habit of a lifetime and try and be helpful. I thought to provide a structure that may help people shape their thinking and decision making. So, I thought I would start with the notion of “how to build”.

Sitting on the train, watching the countryside whizz by (yes commuters, LNER trains do really whizz), I thought I would do a web search using just that term. First up was Caitlan Moran’s most excellent novel (and soon to be film I now know) “How to Build a Girl”. If you haven’t read it, the novel deals with reinvention, escape from poverty and is, The Guardian describes, a “quasi cautionary tale”. So that helped me a bit. The follow on “How to build a really solid shed” and “How to build a computer” seemed to offer little to the aspiring PCN builder. But for light relief in a much-troubled world, “How to build a rollback can” is a video worth watching. Well worth a few minutes of your life and please let me know…why?

But that and many other “how to” tips offered nothing. I thought the current guidance we all have on PCNs would yield great insight. Whilst it dealt with some good technical issues for the next year or so, it offered nothing useful in way of decision making other than to stress this sits with GPs. Exactly where it should be you shout. The review document issued on 31st January was quite a good read. I don’t mind admitting that. The review placed the future thinking and structuring primary care in the hands of practices, LMCs, Federations and maybe even CCGs. Whilst CCGs do have a role, according to the current guidance, dare I venture, this is more an arm’s length thing than has previously been the case. Application of guidance is often different in practice.

So, I thought to be helpful I’d draw on all of the above, mix in a jam filling of strategic thinking and add a topping of 30 years practical experience delivering change. You can always ignore it and develop your own framework. And more guidance may emerge of course, dealing with issues arising like contiguousness (yup, a real word).

Right now, I suggest you might want to start by undertaking a little strategic thinking. Not something primary care has been able to do much in the past. I suggest you start thinking short, medium and long term. That means 1 year, 3 years and 5 years in my opinion. That’s about all you can do right now but do keep an eye on the very longer term too. Maybe draw on any random 10-year forward plan you have to hand. Think about how your operating environment will look like in the future, what things are likely be the norm and the things you should start thinking about now so you are ready for the future.

Spoiler alert. Some the following short-term things you might want to consider are clearly PCN-related. Recant regularly the mantra “hard bottom-soft top” in relation to the “30 to 50” sizing. Not everything fits snugly. Typically, that size implies maybe 3 to 6 practices per PCN (not always) and could imply for some, options regarding PCN composition. You will need to consider the “right mix” of practices which could imply hard decision making about who is in your team and who is not. That in turn has implications for neighbouring PCNs which in turn impacts on the way you ICS will work. And another PCN composition issue – which practice will lead? Which is best placed, best and biggest? How will you decide between you those issues? In some areas, the LMC is providing a helping hand, in others, the CCG. But in many, GPs have been left to do that thinking.

Do you know what factors are most important at arriving at a decision? What informs your decision to include one practice over another? What are the “competing” options locally? What local, strategic decisions do you need to consider? Your deliberations and thinking will, of course, consider similarities, commonalities and factors that will make your PCN “whole”. Able to offer joined up thinking and turn this DES-driven renaissance into ground-breaking development for primary care.

Try then thinking about the 3-year horizon. Difficult I know, but necessary. But note that getting year 1 right is the most important thing right now. Think about where PCNs could take you. Think about where your neighbouring PCNs will go based on your short-term decision making. What will they be planning? This is not a competition but is about thinking strategically. And then think abut where your ICS will be in 3 years. Where will the wider health economy be? What’s going on in there?

And then, less easy to complete, think about the same questions in 5 years. You get the idea.

To help, we’ve put together an issues framework that might support decision making. Nothing involving rocket science (you already have the NASA web address) but it may help. Drop me a message and I will send you a PDF copy.

I am sure you will have already started your thinking and discussions. But this may encourage you think a bit more strategically and better inform your collective discussions.

Key changes in the new GP contract

The GP contract agreement announced this month (February 2019) has already been hailed as one of the most significant changes to general practice arrangements and will introduce widespread changes aimed at addressing workforce and workload pressures facing primary care.

Watch our short film which explains the key changes in the new contract.

What? Another NHS Publication? This One Matters Lots

The GP contract agreement announced this week has already been hailed as one of the most significant changes to general practice arrangements and will introduce widespread changes aimed at addressing   workforce and workload pressures facing primary care.

The package includes a deal covering the next five years with various changes going live throughout the five years. This year, yes 2019, the focus will be on creating Networks and to start workforce expansion. Next year will bring further workforce expansion, additional funding and service reconfiguration under the new networks. Change starts to happen from April 2019 with more support and resources for general practice, increased funding and assuring GP’s leadership role at the centre of primary care.

There have already been several similarly “big” announcements recently and more detail is set to follow.  However, it is fair to say that, alongside the recent publication on the NHS Long Term Plan, this makes a lot of bedtime reading.

In this explainer, we’ve picked out our top five things you may want to know from the initial headlines. What do they may mean for primary care? What are the implementation challenges and what are the opportunities? Maybe also take a few minutes to watch the BMA’s Richard Vautrey in a short video explainer. This gives you great highlights – only 7 minutes of your time.

Top five takeaways

1. Primary Care Networks are important. Very important. 

In the NHS Long Term Plan, Primary Care Networks are cited as being ‘an essential building block of every Integrated Care System’, and under the Network Contract Directed Enhanced Service (DES), general practice takes the leading role in every Primary Care Network (PCN). Happily, general practice continues to be fundamental to the future of primary care. The creation of PCNs is a key feature of the new contract. A highlight being that additional workforce and linked funding will be available through the new PCNs. Hurrah. How much and for how long I hear you ask.

2. There’s additional funding for GPs – through PCNs (see, said they were important!) 

Big numbers follow. Like overall funding of £2.8bn over a five-year period, through practices and networks. In addition to workforce costs (for the additional workforce and the clinical director – don’t worry we’ll come onto that) each network will receive a recurrent annual payment of £1.50 per patient (an extension of the current CCG funding, but now non-discretionary). That will be used by the network practices to support their development and work. Additional funding has been added to the global sum, for practices to establish and engage with networks.

If every network takes up 100% of the national Network Entitlements, including a recurrent £1.50/patient support, plus a new contribution to clinical leadership, £1.8 billion would flow nationally through the Network Contract DES by 2023/24. Double hurrah I hear you say. But what do you have to do for this money?

3. It addresses workload issues resulting from workforce shortfall  

Yes, it does say that. But insert own comment first, then read on. PCNs will be guaranteed funding for an up to estimated 20,000+ additional staff by 2023/24. The scheme will meet a recurrent 70% of the costs of additional clinical pharmacists, physician associates, first contact physiotherapists, and first contact community paramedics. And 100% of the costs of additional social prescribing link workers.

By 2023/24, the reimbursement available to networks amounts to £891 million of new annual investment. Practices will continue to fund all other staff groups including GPs and nurses in the normal way through the core practice contract, which grows by £978 million of new annual investment by 2023/24 and will support further expansion of available nurse, GP and other staff numbers. I am sure you have a few questions about that including, what happens after five years. Leave that for now. We will return to it soon.

4. The new Network Contract DES for Primary Care Networks goes live from 1 July 2019

GPC England and NHS England are committed to 100% geographical coverage of the Network Contract DES by the Monday 1 July 2019 ‘go live’ date. So, it goes without saying close working is needed between Clinical Commissioning Groups and Local Medical Committees to help ensure this goal is met. Those words could be described as being a bit of an understatement. Every practice will have the right to join a Primary Care Network in its CCG and have a right to participate in the Network Contract DES. A typical practice will receive over £14,000 each year from April 2019, in return for their initial and then continued active participation in a PCN as demonstrated by signing up to the Network Contract DES by 1 July 2019 and their subsequent participation.

5. There will be seven national service specifications 

You are probably worn out by now. But here is a little bit of detail you will need to read more about. (Watch this space). The increase in investment under this agreement includes the introduction of seven specific national service specifications under the Network Contract DES. These seven specifications give effect to most of the NHS Long Term Plan goals for primary care. PCNs are being encouraged to make early progress in each of these areas ahead of formal introduction of the requirements and will work to provide early detail of the evolving service specifications to facilitate that. The seven are focused on areas where PCNs can have significant impact against the ‘triple aim’. This includes improving health and saving lives (for example from strokes, heart attacks and cancer); improving the quality of care for people with multiple morbidities (for example through holistic and personalised care and support planning, structured medication reviews, and more intensive support for patients who need it most including care home residents) and helping to make the NHS more sustainable (for example, by helping to reduce avoidable hospital admissions). During 2019 and 2020, NHS England will develop the seven specifications and seek to agree these with GPC England as part of annual contract changes. Lots of detail here and more reading needed. Did you say you had trouble sleeping?

Final thoughts 

So, there you have it, some of the key highlights from the report. I’m sure you’ll continue to see further summaries as people continue to review if over the next few days. It’s also worth reading the report in full if you get a chance. We will be providing some meaningful perspectives over the coming weeks, incorporating real life views of practices and those coming together to work at scale already.

For me the big takeaway is collaboration and the need for practices to be proactive in formation, as well as acknowledging the important role of GP federations to support the formation and operation of PCNs. Quite simply the primary care sector needs to demonstrate new ways of working together. And whilst appreciate this is not a simple task, PCNs are going to be fundamental in the not too distant future. Read the bit on the above BMA link to see what you have to do next. Not much but lots of formation work is needed in short measure. We have done a lot of that recently you will be happy to know,

In my next blog we’ll look at how to overcome the challenges to create successful PCNs and the benefits they can offer primary care.

ATSCALE works with primary care to improve the way clinical services are provided. We also support change through collaboration, networks and neighborhood working. We do this through our work with commissioners, GP federations and GP practices across the UK to enable at scale working and to support the creation of primary care networks.

We see working with collaboration and merging practices as the future. Our team are working extensively precisely on this area of work. We’ve a great track record and see the results of at scale thinking with many practices. We are looking forward to the considerable challenge of delivering the ambitions of the PCN’s.

GPC England announces GP contract agreement 2019/20

GPC England has announced that it has negotiated a deal which will span the next five years. In 2019 the focus will be on building the foundations, creating Networks and starting to expand the workforce.

From 2020 onwards the focus will be on further increasing the workforce, additional funding and services reconfigured (as decided by the networks).

The most substantial changes commence from April 2019. The changes should provide much needed support and resources for general practice, expanding the workforce, reducing workload, increasing funding, retaining GP and partnership autonomy and ensuring GPs have a leadership role at the centre of primary care.

You can read a summary of the deal, and the various attachments for each of the specific areas of contract change, which outlines immediate preparation, 2019 requirements and planning for future years on the BMA website.

Mars is blue. Who knew?

Well probably all the world’s scientists. And maybe a few million people interested in stargazing. But OK, not me.

So the latest amazing pictures from NASA’s probe of a blue sunset on Mars was a bolt out of the …… no, can’t bring myself to make such a cheap joke…

What occurred to me when I saw this picture was how our assumptions and preconceptions can so easily be challenged by a bit of data, a touch of fact and even a pinch of evidence. In our working life, we sometimes fall back onto our preconceived ideas and norms, often by default and often without even noticing. In my work, I’ve come across many examples of decisions about the future being made on the basis of past circumstances and discussions. Often arising from years ago.

In recent GP practice merger discussions, I’ve come across quite a few examples of this. Such as “we don’t think they will make a good partner in our at scale entity because they <insert own example here> a few years ago”.  And a good few “we spoke to them about <insert own service here> and we couldn’t agree a clear way forward”.

And I could go on but I’m sure you get the idea. Is it right that our futures are constrained by something that happened in the past? Clearly, the answer is sometimes yes and I get that. But often, we’ve forgotten why we don’t engage with someone, don’t involve them and don’t value their involvement. The blue sunset picture reminded me not to assume anything. As someone famous once said, to assume is to make an ass out of you and me. Or something like that.

So the takeaway (aside from marvelling at this fab picture) is for you to challenge yourself to consider your current preconceptions, recall where they came from and when your formed them. And then to consider how those preconceptions may be holding you back from making the most of your future. I know I will bore people about the “real blue planet” for a good few months.

GP forward view

GP Forward View – is ‘on track’

NHS England has confirmed that the GP Forward View – is ‘on track’ two years after it was announced. Primary care director and deputy medical director Dr Arvind Madan also said they are now ‘beginning to see some of the fruits’ of the investment in a recent opinion piece in Pulse.