LMCs' analysis: 'We cannot advise signing up for Network DES'
A group of LMCs has analysed the PCN DES, and concluded practices should not sign up
Summary of Advice to Practices on the PCN DES – April 2020
Many constituents across the three counties of BBOLMCs have asked our advice with regard to whether to sign up to the PCN DES for 2020/21, and indeed onwards. This document serves as a summary. For more detailed analysis please refer to our previous analysis documents of the PCN DES which can be found on our website.
In February we advised practices that following our analysis of the PCN DES, we had significant concerns that as well as having extremely onerous workload requirements, the DES poses a threat to the independent contractor model, the core GMS contract and the autonomy of practices, and therefore we could not recommend practices remain signed up to the DES. Our position and advice have not changed.
Since our advice in February, the Special Conference of England LMCs on 11th March also voted to reject the PCN DES in its current form, specifically by the following motion being passed in all parts.
MOTION PROPOSED BY BERKSHIRE
That conference believes the PCN DES is a Trojan horse to transfer work from secondary care to primary care and that:
(i) this strategy poses an existential threat to the independent contractor model
(ii) there should be immediate cessation of LES and DES transfers from practice responsibility to that of PCNs
(iii) GPC England is mandated to urgently survey the profession to get feedback on whether they intend to sign the new PCN DES
(iv) GPC England must urgently negotiate investment directly into the core contract as the only way to resolve the crisis in general practice is by trusting GP partners with realistic investment
(v) the profession should reject the PCN DES as currently written
Therefore, the policy of the England Conference of LMCs is that the profession should reject the current form of the PCN DES.
Conference also voted that the deadline for opting in or out of the PCN DES should be pushed back to October 2020 to allow time for detailed modelling, costing exercises, details of impact assessments etc to be published to inform practices and networks of the risk and financial viability of remaining in the DES. This was by the following motion being passed in all parts:
MOTION PROPOSED BY DERBYSHIRE
That conference is concerned that, despite a radical overhaul of the PCN service specifications, there remains a significant funding gap, and demands:
(i) to know as soon as possible whether an impact assessment, including PCN level and practice level modelling, was carried out by the BMA prior to the agreement of the GP contract
(ii) that there is an urgent costing exercise undertaken which will better inform primary care networks as to the financial viability of signing up to the scheme
(iii) that the deadline for practices to sign up to the 2020 / 21 PCN DES be deferred until 1 October 2020 to allow time for all associated details to be published
(iv) a moratorium of one year on the implementation of all specifications within the DES to allow time for PCNs to begin to develop the required workforce, and to scope the required workload for feasibility and viability in the longer term.
The above motions of the Special Conference of England LMCs and indeed our own guidance occurred before the events of the COVID-19 pandemic. Given recent events it is now even more necessary that there be an extended sign up window and moratorium on new service specifications and requirements so that practices can focus on core services, and the pandemic response. We therefore find it alarming and astonishing that NHS England continues to implement the enhanced services of the DES as planned, during the greatest pandemic of the last 100 years.
Whilst the SMR specifications have been delayed until 1st October, they have not been removed entirely. The Enhanced Care in Care Homes requirements remain in place, and the Early Cancer Diagnosis requirements remain an expectation ’unless work to support the COVID-19 response intervenes.'
Threat to the Independent Contractor Model
We continue to maintain that the PCN DES poses a threat to the independent contractor model, as supported by the policy of LMC Conference as per motion 23 above. In particular our concerns are:
• Performance management of practices at Network level
• Direct oversight and scrutiny of PCN Clinical Directors by NHS England
• Erosion of locally commissioned practice level services such that practices become dependent on the DES
• Emergence of lead providers holding contracts and PCNs becoming dependent on these providers
• Ever closer integration of PCNs into de facto Integrated Care Provider structures
• The transfer of practices’ Primary Medical Services contracts to ICPs or lead providers
• GP partners being forced into an all-salaried service
Relationship Between the DES and Core Contract
The blurring between the DES and the core contract was a recurring theme at the Special Conference, being a concern raised by various LMCs around England. As with all DESs, a variation is made to the core contract when you sign up tying the DES to the core for the duration of the DES. Whilst this isn’t ordinarily a concern, the vast size of the PCN DES, the onerous requirements of its specifications, the references to GMS services in the DES contract and its increasing integration into integrated care at large scale gives us cause for significant concern regarding the future of traditional partnership General Practice.
Potential Alternative Models
We continue to maintain that the concept of practices working together in networks as a model of delivery remains sound, and the benefits of practices working together and delivering some services at scale must not be overlooked. For the avoidance of doubt, it is the DES, its specifications and the NHS England agenda of regional large-scale integration which we have significant concerns about, not the concept of PCNs themselves as a model.
We would therefore advise that any practice(s) which choose(s) to opt out of the DES should consider remaining in their networks, either as peripheral members (where a single practice opts out) or as a non-DES PCN with altered network agreement (where a PCN does this as a whole). This would enable the localised commissioning of services at network level, without the onerous requirements and risks of the national DES.
Notwithstanding this, we are aware some practices have specific circumstances not amenable to working at scale in this way (e.g.: rurality, financial, population and size) – The LMC wishes to reassure such practices that we support their right to self-determination and will support all practices however they choose to work.
Consequences of Opt-Out
Practices which choose to opt out would cease to be entitled to the following financial entitlements, listed below at practice or PCN level (2020/21 amounts).
|Practice level||Network level|
|Network participation payment||£1.76|
|Network support payment||£1.50|
|Clinical director payment||£0.69|
|Investment & Impact Fund||£0.74|
|Care Home Bed Premium||£0.99 (based on average)|
The funding pots shown above under 'network level' are attached to the requirements of the PCN DES, which an opted-out practice or PCN would no longer be required to deliver. Therefore, this cannot be considered truly 'lost income' as practices would have never received it anyway, especially as our analysis showed the cost of delivering the service specifications required is greater than the funding of the DES.
Opted out practices would also cease to be entitled to receive the Extended Hours funding, although they would also not be required to deliver any Extended Hours services as that DES was rolled into the PCN DES in July 2019. The Extended Hours funding is £1.45 per head, although it is worth noting it was reduced by 23.6% from £1.90 per head when it was rolled into the PCN DES. How Extended Hours would then be delivered to patient populations would be up to the commissioner, however the LMC would support this being commissioned locally to practices either individually or as part of non-DES networks, in the best interests of patients.
At a network level, PCNs who have opted out would no longer be entitled to the Additional Roles Reimbursement Sum (ARRS). PCNs would need to take an individual view as to whether the benefit of the reimbursement toward staff outweighs the requirements of the DES and workload attached to it. Our previous analysis has explored this for an average PCN and our professional view is that the benefit of the ARRS is negated by the workload of the DES. Should practices/networks opt out, whether they choose to continue employing their ARRS staff without funding will depend upon the way in which they employed them, who holds employment risk and their contracts etc. This will be an individual PCN level decision.
As the requirements of the DES mirror the NHS Long Term Plan, if large numbers of practices/networks opt out en masse, then commissioners will need to look at alternative ways of commissioning these services. The LMC’s preferred approach would be for network services to be designed, specified and commissioned at a local level.
Despite the above, practices would remain entitled to the other entitlements outside the PCN DES including the increase in Global Sum, QoF, vaccinations and immunisations, and the £20,000 partnership incentive scheme.
• Our prior analysis of the PCN DES has been detailed and extensive, this has not changed, and we reject it in its current form
• We do not believe the DES has sufficient benefit to practices to warrant LMC approval and therefore cannot advise our constituent practices that they sign up to it
• Conversely, we are not necessarily advising all practices opt out. Whether practices and networks choose to remain signed up is an individual decision only they can make
• The LMC will support and assist all constituent practices, whichever course of action they choose
• If you choose to opt out, we recommend remaining in your networks and working with commissioners to find local solutions to enable working at scale where it is beneficial to practices and your patients
• The potential consequences of the DES are not clear. The effect it will have on your practice and contract remain unclear and may be irreversible. We are concerned this may be the last point you can opt out without causing irreversible adverse consequences to your practice
• It is not yet clear whether remaining opted in at this stage would be reversible. However, opting out is reversible. If you choose to opt out, you are free to opt in again at a later date
The LMC Secretariat remains available to answer any individual queries practices or PCNs may have, and we encourage practices to contact us if needed at email@example.com
Dr Matt Mayer, chief executive officer
Dr Richard Wood, chief executive officer
Dr Simon Ruffle, chair of board
Dr John Rawlinson, chair, Berkshire LMC
Dr Stefan Kuetter, chair, Buckinghamshire LMC
Dr Raman Nijjar, chair, Oxfordshire LMC