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The waiting game

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 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 PCNS here- income last week just shy of £8k. Thats for the week.... not the 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 .

    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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