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Independents' Day

To engage or not to engage…?

Dr Nikki Kanani

Please note - we are pre-moderating comments on this. We should have made this explicit when this was first published and I apologise for not doing so, especially as it was over the weekend. We are more than happy to publish criticism of the policies, but there have been personal attacks in the past, which we cannot tolerate. Your comments will be published ASAP. Jaimie (editor)

 

Over the past month we have seen frustration and concern over the draft primary care network (PCN) service specifications that were being engaged on.

When we first published ‘Investment and Evolution’ last year, we committed to both sustaining general practice and improving the quality of care. We knew this was going to be a tough ask.

Yet we also know that general practice has been struggling. Too many people are leaving the profession and too many doctors report burnout or compassion fatigue. And we have to acknowledge that satisfaction by our patients with access to their GP practices has also been eroding.

The move to supporting practices - large or small - through working within PCNs is the beginning of addressing this. Bringing in more staff. Recruiting more GPs. Creating more of the right type of capacity, so patients are seen by the right person.

PCNs are also intended to be a way of offering better health and care. Locally joined up services, offering evidenced based improvements for patients, designed through seven service specifications, delivering the improvements set out in the long term plan.

The first five of these were published for engagement in late December. Having been unable to publish during the election we wanted to get your views, reflect on them and agree the overall deal with the GPC so that we can make the necessary payment system changes in time for 1st April.

The draft specifications will indeed change before they are finalised

We needed to get the specifications right for the profession and for the public. The first draft was never going to be the last word and we needed your help to get them right.

There was a lot in the draft specification document. It is clear that some felt it was overly prescriptive, or that too much was being asked of GPs. Some may even have felt that this was not what they expected from PCNs.

Many thought that the aspirations of the individual specifications were sound but were cautious of the implied performance management.

Here, we’ve summarised the feedback we received - from over 4,000 respondents (mainly GPs, PCNs and LMCs), and through webinars and twitter chats.

We wanted feedback and we got plenty. We’ve worked through every response. You’ve given us a clear message, so the draft specifications will indeed change before they are finalised.

The themes in the feedback document are informing our discussions with the BMA’s GP Committee. We hope you will find them realistic, workable and fundamentally supportive of general practice, the partnership model and primary care networks - as well as good for our patients.

I want to thank all those who gave up precious time to take part. This is the first time we have engaged in this way and we hope that once you see the outcome of this process you can see we are genuinely trying to get this right.

Dr Nikki Kanani is medical director of primary care for NHS England and NHS Improvement

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Readers' comments (34)

  • Well done and thank you Nikki. Good luck with the ongoing negotiations. This is a crucial time for the profession.

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  • David Banner

    I respect Dr Kanani for having the bottle to write this article, and I hope other responders will recognise her bravery in fronting up for NHSE to the angry mob.

    But let’s face it, PCNs were a Trojan Horse smuggled into the contact at the last minute, with a ridiculously short signing up period. They were “optional” but all our patients had to be in them. And any new investment in Primary Care would come through them. So join or starve, what a choice!
    And once we were herded in, the truth emerges. You can have staff you don’t need or want, and pay 30% of their income for the privilege. You can use these new staff to do a huge amount of extra work we are about to saddle you with, even though they are not skilled to do it, and their numbers are pitifully few. And all the time they freed up means you can visit every patient in a Care Home once a fortnight. Oh, and that’s just for starters, we’ve lots more Blue Sky Xmas wish list projects in the pipeline!

    Clearly NHSE is clueless about the depth of the crisis in Primary Care. Either that, or they are deliberately putting the final bullet in the head of the terminally ill partnership model.
    Either way, they need to realise that their grand plans are totally unworkable, and that the trickle of older experienced GPs out of the profession will become a flood, whilst younger doctors wouldn’t touch GP partnership with barge pole.
    Scrap the DES. Entirely. Disband PCNs. Why are GPs sat in meeting rooms instead of surgeries where they are needed? Go away and think again. We need lifeboats, not more torpedoes.

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  • Networks don’t help in my opinion - they just create more work, responsibility and stress and take clinicians from clinical work. Why does every “improvement” take me nearer to quitting?

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  • No

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  • It would be nice if there was more straight talking and less platitudes....in simple numbers show people how they will be better off under your proposals........workload and remuneration wise......if there is no clear AND significant improvement then all this PCN talk is a waste of time......... I think I'll stay in Australia......no PCNS here- income last week just shy of £8k. Thats for the week.... not the month......no silly QOF stuff here..... just look after the patients.....

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  • Tantalus

    Frustration and concern?!
    I think that’s putting a spin on it.
    Try anger and outrage.....

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  • PCNs are solely for those naive cardies who allow themselves to be manipulated by Kafkaesque Macievellian delusionalism. The rest of us have moved on. Nikki you’re toast.

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  • Hi Nikki,
    I guess I am someone who should be getting targeted by these changes. I work minimally in general practice, working more in my area of special interest which pays less but means I go home not feeling depressed. However I do enjoy the work of general practice, and under the right circumstances, would love to be a full time GP. I’m not greedy, but I won’t do a job which makes me ill. All I can say is that the initial draft made me wonder if it was a deliberate attempt to destroy general practice. It clearly wasn’t written by anyone who had a sentiment that general practice needs SAVING. I talk to dozens of other GPs locally who are of similar thoughts, which if multiplied nationally, means there are thousands of GPs put off doing more sessions or becoming more involved as the situation at present is so diabolical. NO OTHER EQUIVALENT COUNTRY TREATS ITS GPS THIS BADLY. Major changes are needed Best Wishes

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  • Nikki, I am sorry to burst the bubble in which NHSE PCN directors live, but I don't think any of the specifications in the draft DES were offering "evidence based improvements". There isn't a single GP I know who is "broadly supportive of the aims" (of this wacky proposal).

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  • Vinci Ho

    To be or not to be
    Dear Nicki
    You might not know who I am and indeed , as an ordinary grass-root GP, my opinion only stands as one of the thousands amongst my honourable colleagues up and down our country during this most extraordinary ‘feedback’ exercise .
    I am grateful for your sincerity to write this article on this platform at a crucial , critical moment of history of general practice in NHS .
    What is absolutely crystal clear , right in front of us(and the country ) , is a serious GP retention and recruitment crisis and the consequences of allowing this to deteriorate are irrevocable. Question is , whether it is also unforgivable if the current government and its subordinates continue to misunderstand and undermine the genuine reasons why we have reached this hitherto situation .
    The model of a tax-driven , publicly funded health service is understandably under scrutiny all the time . The argument of administrative costs to keep the system afloat could become an unnecessary burden as the level of bureaucracy becomes exorbitantly high . Perhaps , this is one of the reasons why the ideology of moving towards more privately-run models and service providers , is always alluring . I accept that the reality is so often somewhere between the two extremes of argument.
    Then we , human beings , continue to fail in learning from history . The track record of recent government(s) and NHS England in preventing this crisis of GP retention and recruitment is evidently poor . Some might easily jump to the conclusion that it was the government and its associated authorities which had created this crisis . All in all , the story so far has substantially dented the trust of GPs in the government and hence , NHS England . Confucius said , ‘an authority will not stand without the trust of people ‘(民無信不立) in the book of Analects .
    And , Publius Gornelius Tacitus (56-117 A.D.), a historian and a senator of the Roman Empire, said neither good nor bad policies would please the governed if the government is unwelcome, which was later called "Tacitus Trap" in political studies.
    Trust only comes after credibility which is , in turn ,derived from the track record of an authority .
    xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

    This brings back to the fundamental question ,’ What is the current level of trust between general practitioners in NHS and NHS England?’ And I would argue that it is politically naive to claim ‘good’ up to this point of time . We , GPs , are always on the receiving end and it is the obligation of NHS England to bridge the gap . The fashion this draft of PCN service specifications was released on 23/12/2019 and more essentially , its content have failed to slake this desperate quest to re-establish trust between us and NHS England .
    While your predecessors had failed to convince us that they were the benevolent leaders governed by their moral compass , I am cautiously optimistic that you can potentially be the ‘record-breaker’ and help the government to fulfil promises .
    I have re-published my comment (below this one)specifically for the service specifications and it was enclosed in my original personal feedback , in case you were too inundated by all the feedbacks .
    Watching the unfolding of the story of this human crisis of Wuhan coronavirus right in China right now , I am further reinforced in my belief that 21st century politics can only survive with better transparency, honesty and humility.
    Vinci Ho
    A GP
    An ordinary PCN clinical director

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  • Vinci Ho

    NHSE official admits ‘we need to make changes’ to draft network specifications
    Vinci Ho's comment 15 Jan 2020 0:26am
    Spent four hours two days ago to read through the whole draft and condense it into a power point presentation for discussion with my fellow colleagues in my PCN yesterday. We also had lengthy discussions in our PCN alliance in Liverpool today .
    If we trace back this story from the beginning:
    There is fundamentally a social-norm-broken demeanour of NHS England in how this document was released shortly before Christmas with a deadline set at only two weeks into the new year . This is reminiscent of how our almighty prime minister was trying to block the parliament to debate Brexit through prorogation shortly before the general election last year . Whether this is a conscious effort or not , the impression of an imperious NHS England has undoubtedly generated an extraordinary, omnipresent swathe of negative responses from GPs , PCNs , LMCs etc . In the heat of the moment ,many colleagues are angry fraught with sentiments of betrayal and incredulity.
    Then it is about the substances in this document which in effect , created more questions than answers :
    Before long , every section requires a ‘clinical lead’
    (1) Structured Medicine Review and Medicine Optimisation:- It appeared to be quite logical to have these tasks to be implemented by pharmacists employed through the extended workforce deal in the PCN DES .However , the fact that practices have to pay 30% of their salaries ( in contrast to that in social prescribers) , could always pose additional financial risks on practices . 100% reimbursement , to me , is the only way out to ensure these SMR/MOs can potentially transform general practice in line of the vision of NHS England desired. Realistically, this category easily requires two clinical pharmacists for an average sized PCN with 30,000-50,000 in population.
    (2) Enhanced Health in Care Homes :- this part is widely considered as flagrant violation to how GPs believe that these patients in nursing homes can be looked after , given the current resources available. The evidence of improving quality of care is clearly yet to become credible and plausible for putting this minimum two-weekly ‘home round’ requirement into a black-and-white contract . In fact , one would argue that the ‘evidence’ used by NHSE is estranged from what clinicians would normally adopt and is merely a dogmatic imposition.
    Yes , there seemed to be a leeway of arranging community geriatricians to do these rounds alternatively but it begs the serious question of how realistic that would be .
    Nevertheless, there is also the part where PCNs would bear the obligation to train , educate and even vaccinate staff in these care homes . I would cynically challenge that the owners of the homes would be more than euphoric as they could make some investment savings?
    (3, 4)Anticipatory Care and Personalised Care :- Again , it seems sensible to target certain cohorts of the population and identify them into certain ‘dynamic lists’ . We are already using electronic calculator software in the system to record frailty index for all patients aged 64 and above , from which we identify and label moderate or severe frailty. Other cohorts like end of life , type 2 diabetes and MSK conditions are all mentioned and easily identified . The road has already been well paved .
    But the approach advocated in this document had heavily skewed towards writing up personalised care and support plans (PCSPs) and recording shared care decision conversations , number and quality of which are both measured metrically . Evidence of merit is yet to be established. The obsession of collecting so much health data not only creates enormous amount of administrative workload but also raises the question of the intent of NHS England .
    Furthermore , there is also a very steep and prescriptive timescale requiring so many patients to be referred to social prescribing services . The ultimate ambition was to refer 16-22:1000 weighted population cases to social prescribers . Hence , for a size of 30-50,000 PCN , there would be 480 to 1100 referrals . Patient Activation Measure (PAM: a 100-point, quantifiable scale determining patient engagement in healthcare. ) is another tool adopted to satisfy the gluttony of data collection centrally .
    Of course , last but not the least , we have to measure the number of the most contentious Personal Health Budgets annually .
    (5) Supporting early cancer diagnosis :- very much politically correct as we all have been working our socks off , referring more and more patients by two week wait rule everyday . Thanks to NICE significantly lowering the positive predictive value for cancer screening parameters .
    As I reiterated on this platform time to time , the bottom line issue is about improving cancer survival ( as compared to our OECD counterpart countries ) by shortening the referral to treatment time (RTT) . The recommended target of 62 days is currently well out of reach . The fact that we , GPs , are referring so many 2WR cases everyday , has already well consumed the capacity of imaging , endoscopists, surgeons and oncologists etc .The number of false positive cases to be excluded is burning the system out . Hence , the emphasis of NHSE to push GPs to refer more in order to ‘detect’ earlier is running under the caveat of the law of diminishing returns. No wonder the target of 62 days of RTT is becoming more distant reality. I can only hope the cancer academics and NHSE can come down from the top floor of the ivory tower to face the reality on the battlegrounds.
    xxxxxxxxxxxxxxxx
    Yes , extreme conditions demand extreme measures . It is most disappointing but also ignominious that NHSE is barking up the completely wrong tree as the extreme condition GP currently is namely, recruitment and retention crisis .
    The PCN service specification draft is simply killing the chicken before any more egg can be laid .

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  • PCNs were sold to the profession as being (in part) to ease some of the pressures on general practice and GPs. The real intention (to dump as much additional work onto PCNs, and by extension GPs, as possible) has become very clear since. For anyone in NHSE to have developed and then signed off that draft spec shows either:- It was deliberate, so a "better" watered-down version could be unveiled after the consultation, or shows such an incredible lack of understanding of what general practice is currently like to work in, that those involved should consider their positions. Some things are just too wrong to engage in, particularly when the other party has shown their hand, and what is in store for PCNs if they continue. The only honourable response from NHSE at this point would be an apology, "we got it horribly wrong" and to start again.

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  • National Hopeless Service

    The level of continued ignorant detachment from the realities of coal face general practice from NHSE is outstanding. You can bleat on all day about improving patient care and outcomes but if there is no functional primary care doctoring you have uttrely failed from the outset. PCN were being sold as NHSE having an interest in trying to reduce GP workload but the reality behind the DES is the complete opposite. There is absolutely nothing in this contract/DES that will stop the attrition rate of partners. Without partners owning/leasing premises and being the employers of this 'army' of new staff (my half session primary care untrained pharmacist is proving more of a workload hindrance than a saviour) general practice will continue to die.

    Do something useful with your time Nikki, totally rip this DES up and start helping not hindering the general practice that you allege to support. If you dont I like many GPs in their late 50s will just pack up and leave as we have just had enough.

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  • National Hopeless Service

    '

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  • How convenient is it to interpret feedback the way you want to interpret it
    And how difficult was it and is it to understand that general practice does not need more resource for more and undeliverable work, it does want to be forced into groups but wants to work collaboratively by choice, where it makes sense to its patients and practices and most importantly it has been crying out for resource into CORE GMS to help struggling practices , not some fancy innovation conjured up in fancy offices by peopl who have no grassroots interest at heart and will throw general practice off the cliff for their gongs

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  • David Banner

    Kudos to Dr Kanani’s courage in fronting up to Pulse readers. It takes bottle to defend such a catastrophic car crash in front of the angry mob.

    But PCNs have to be abolished if NHSE has any credible desire to preserve GP partnerships. Otherwise the only logical conclusion is that they are deliberately shooting the last bullet into the brain of a model that has been slowly strangled in the last decade.

    PCNs were smuggled into the 2019 contract at the last minute, supposedly voluntary, but all patients had to be in one. Oh, and if you refuse, forget any future investment. And you’ve got 5 minutes to organise yourselves. Then you have to waste hours of valuable consulting time in pointless meetings.

    But never fear, you can have funding for staff you neither want nor need......provided you pay 30% of their income yourself. That should give each practice about half a day a week, if you’re lucky. Can’t recruit? Well, tough. Because now we reveal the hidden agenda. A monstrous DES with huge amounts of extra work. Why are you complaining? You joined voluntarily, accepted new staff, now we want our pound of flesh. Wouldn’t it be lovely if you GPs saw every one of your Care Home patients every fortnight! And maybe your shiny bright PCNs could take over OOH care next year too.

    Blue Sky Utopian thinking from people who either don’t know or don’t care that GPs are on their knees. Older GPs ready to ditch their practices, and younger ones who wouldn’t touch partnerships with a barge pole. There simply aren’t the GPs to realise your Brave New World, and those left will scarper if this madness continues.

    If NHSE are really listening, then listen to us hapless ground troops in the trenches, not our deluded generals. General Pracice is dying. We need to be left alone for a few years whilst the politicians magic up their promised 6000 recruits, which we doubt will ever materialise. Abandon PCNs quietly now, instead of triggering a slew of messy resignations before their inevitable chaotic collapse later. NHSE can emerge with some dignity by dropping the whole disastrous charade immediately, instead of poisoning their reputation even further.

    Rip it up and start again. Please.

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  • No

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  • there will have to be pretty major differences to the spec for us to engage again.
    The feeling out here in front line land is not happy.
    All this could also be pretty academic and irrelevant if the corona virus takes off in the UK.

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  • I am very grateful for your continued hard work, and the engagement process. I have yet to hear anyone say ‘we got this wrong’ despite overwhelming evidence that the first draft was an unmitigated disaster. It would be nice to hear some candour on that topic and go a long way to restoring faith.

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  • There is no question that you are engaging, but the fact that these specifications were released to begin with means that NHS England either completely misunderstands general practice or doesn't respect GPs at all. How on earth did you think things like 2 weekly care home visits could be bolted on to an overstretched service.

    I'm sorry but only a moron would think that this would stabilise general practice. It's shameful that it was ever published.

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