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A faulty production line

NHSE official admits ‘we need to make changes’ to draft network specifications

An NHS England official has admitted changes to its proposed primary care network (PCN) DES contract are needed to ensure practices can deliver new service specifications. 

NHS England director of primary care and system transformation Matt Neligan acknowledged there had been 'lots of feedback' on the service specifications so far and that NHS England was 'committed' to revising the plans.

He said NHS England needed to take both the strength of feeling among GPs - and the specifics about the content of the proposals - 'seriously'.

In a separate webinar held today (Tuesday), NHS England hinted at a roll back on the care home specification, saying that the intention is that enhanced care home is provided by the multidisciplinary team rather than GPs as individual practitioners, referring to the fact that advanced nurse practitioners already visit those patients.

Mr Neligan said 'we cannot afford' to make the plans 'over-ambitious,' but also warned the additional £4.5bn of funding being provided as part of the NHS long-term plan 'should create room to do more'.

He urged GPs to share any concerns they have about the current specifications, including whether they think the timetable is realistic.

NHS England director of primary care Dr Nikita Kanani also reassured GPs that feedback will form the basis of the final DES contract requirements. 

She tweeted: 'Everyone is working flat out to process responses so we can rethink and rework as quickly as possible, so the profession isn’t left wondering what’s happening.'

The network proposals, revealed in a draft document published on 23 December, are currently subject to an open consultation, due to close today.

PCNs and LMCs are recommending GP practices not to sign up for the network contract DES in 2020 as it stands due to the 'overwhelming clinical and financial burdens' it would place on GPs.

In a series of tweets this week, Mr Neligan wrote: 'Last couple of days to comment on the PCN services specs. Lots of feedback to date that tells us we need to make changes. We are committed to doing just that.

'There are some really important points about this work: these are draft and this is a proper, comprehensive and dynamic engagement exercise, being conducted "at scale". The feedback that we get will influence the final versions that we negotiate.'

He added: 'We cannot afford to make them over-ambitious: we would like PCNs to welcome the final versions as sensible expressions of ambition.

'Clinical directors and general practice teams should feel the final versions are deliverable and that they are aimed at the right areas

'Equally we cannot afford to make them under-ambitious: the £4.5bn going into primary and community care in the NHS long-term plan should create room to do more and these specifications reflect part of that ambition.'

The specifications first drew criticism when it was announced that GPs in networks would have to carry out fortnightly care home visits in 2020/21.

This was followed by resignations of PCN clinical directors across the country

In addition, a Pulse survey found that 80% of partners will refuse to sign the network DES contract if proposals go ahead.

Readers' comments (15)

  • Time to face the music NHSE,the GP service is on the verge of collapse,every over branch of the NHS apart from the regulator and the management class is as well.We seem to be in total service failure and the main culprits have been given a 5 year mandate to finish the job.As you are finding out the work force will make a noise and create a stink as the ship sinks to make sure the general public know where the responsibility lies.The turkeys are sick of helping you plan Xmas dinner.This pi@@ poor contract need shelving.The unfunded workforce and DESs are ill thought out you do not understand the dire straights we are in.Listen before it too late and act.

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  • HSJ is reporting NHS England are suggesting removal of anticipatory care, personal care, and weakening the nursing home visits components of the DES.

    The DES still looks terrible from here...

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  • Tactics, tactics. Announce horror, recant, redraft, and end up with 2/3rds of what you want anyway, the rest can wait till next time.

    Is it not time we started thinking about the relationship we have with these people?

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  • Vinci Ho

    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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  • Vinci Ho

    Just submitted my ‘feedback’ enclosing this long comment to NHSE (and PULSE link for this article )
    Only hope that this could be the last straw on the camel’s back , by any slightest chance just the deadline (today)

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  • nhs costs 143.4b for 2020-2021. GP gets 11b, ie 8.3% of budget, includes drug prescribing by GPs. we do 300m appts a year, ie 90% of the work, so why don't we get 90% of the budget. A^E see 23m per year - one year of GP funding per patient costs less then 2 x A^E visits. The NHSE still want 2-3% savings every year made. the funding is screwed against general practice. its not a profitable business to be in. when businesses reach this point they close.this is why general practice is failing. no money no business. You employ hospitals and private companies to do this you lose all the goodwill and unpaid overtime thats been provided for over 70 years by GP in the NHS. Whatever costs you budget for you have to double them in this scenario. damaging GP will increase costs and reduce efficiency. if you can't see this then you don't understand how the NHS works and why it is now failing.

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  • It is like an exercise in how to demoralise an entire profession - the same profession in which you are trying to improve retention. It would be hard to make this up......

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  • The NHS is broken.
    We are not at breaking point but have gone past that. How do you judge a restaurant or shop that closes 1/3 of the year (no routine operations), waiting list for months, staff with very low morale and over worked with one sided contracts constantly changing putting staff under stress, unrealistic targets not in keeping with resources given and available time?
    A failed organisation.
    There is no unlimited resources and neither should there be unlimited demands.
    Take us private BMA and free us from the poor over management.

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  • What is beyond comprehension is that NHS England choose to completely and utterly ignore the stress and difficulties in Primary Care. They have totally failed to find the 5000 GPs promised, and by their own admission needed, but still think they can pile on extra pressure.
    What are they thinking?
    Who is this Mr Nelligan?

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  • NHS England don’t care and don’t have any insight because the majority of them have never actually worked in a healthcare role.

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