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A honeymoon period in the PCN marriages of convenience?

The introduction of primary care networks in this year’s GP contract for England has been described as the most substantial change in 15 years. In a blog for Pulse, BMA GP Committee executive member Dr Krishna Kasaraneni went as far as to say ‘one day PCNs might be up there with the introduction of modern hospitals, heart transplants, and the organ donor register’.

The formation of networks resembled a whirlwind romance. Following the announcement on 31 January, practices had until mid-May to organise themselves into new groupings of around 30,000-50,000 patients that are likely to become their main income driver.

At the time, GPs criticised the lack of guidance and the tight deadline, doubting the country’s ability to ‘get this together’ on time.

For full details of the new networks, visit our new service, Pulse Intelligence

Not surprisingly, six months on, these marriages of convenience haven’t all been plain sailing. At the start, CCGs were refusing to sign off networks that had excluded so-called ‘pariah practices’. As PCNs started looking into the detail, many ran into VAT issues and the realisation the funding may not cover the costs of some of the extra clinical roles.

Yet others have taken to it smoothly, reporting that their networks are already starting to show benefits.

Data obtained by Pulse on every PCN in the country – which can be found in full on Pulse Intelligence, our new service for GP practices – suggest it is wrong to think of networks as a homogenous group. The responses revealed more than a tenfold difference in network size around the country, with PCNs as small as 17,500 patients and as big as 190,000 getting the go-ahead.

Regardless of size, next year will bring major changes. For the first time, networks will be required to deliver the first tranche of the seven national service specifications in return for the support and funding they are receiving.

The funding is significant. Practices that joined a network were promised funding through the network DES contract, expected to grow by £1.799bn by 2023/24.

A large chunk of this is to support the recruitment of 22,000 additional workers by 2023/24, including 70% of the costs for clinical pharmacists this year, with physician associates, first-contact physiotherapists, and community paramedics to follow. It is paying 100% of the funding for social prescribing link workers.

As new RCGP chair Professor Martin Marshall pointed out in Pulse in September, PCNs are already facing a ‘big challenge’ to find these additional staff, given the struggles to recruit the 5,000 extra GPs promised by the Government.

Last month, even NHS England director of primary care and system transformation Dominic Hardy admitted that some areas in England would face a ‘real challenge’ in recruiting the extra staff.

This is reflected on the ground. Dr Sanath Yogasundram, clinical director for Octagon PCN in Cambridgeshire, says: ‘We have constant challenges in filling posts with high-quality staff and funding is always tight of course.’

Dr Kasaraneni says ‘PCNs are not exempt from NHS pressures’. He adds that the BMA is hearing about funding and recruitment issues, and practices are not yet seeing signs of workload reduction.

Some say they cannot find the right level of experience for the salary specified by NHS England, or are unable to find the 30% shortfall.

Kent LMC medical secretary Dr John Allingham says: ‘We already have disputes over funding of additional staff between those who already have pharmacists and do not want to contribute to the cost of PCN pharmacist and the rest.’

Some are resorting to other measures to fund pharmacists. NHS England director of primary care Dr Nikita Kanani said in a recent discussion on Twitter that ‘some trusts have covered the other 30% funding of the additional roles, to support practices but then asked the pharmacist to work a day a week on integration issues’.

Meanwhile, Health Education England’s deputy medical director of primary care Professor Simon Gregory told Pulse last month that plans are being drawn up for paramedics hired by networks to work across both practices and ambulance services, so the emergency service does not ‘lose’ its staff.

CCGs are reluctant to release funding for PCNs

Dr Kieran Sharrock

But for Dr Allingham, this highlights the problems of practices being thrown together at such speed. He says this is also evident in the funding of the former extended hours enhanced service, which has been taken from practices and given to PCNs as part of the new network DES.

He adds: ‘Extended hours is a problem. Practices that did not do it are being compelled to contribute to extended rotas and are struggling. The IT to share across PCNs is lagging and leading to delays.’

Another chunk of funding comes from CCGs. But some practices are meeting resistance from commissioners.

Lincolnshire LMC medical director Dr Kieran Sharrock says: ‘Funding for PCNs is being held by CCGs who are reluctant to release it. The system expects PCNs to solve the ills of primary and community care but the resources and contractual changes to support this do not exist.’

The networks are taking up significant time, too. Clinical leads are being removed from practices for a day a week, which practices are being reimbursed for. But as Dr Amit Sharma, clinical director of Wokingham West PCN, Wokingham, says: ‘The biggest issue is the number of requests for your time. There is a lot of requests for meetings from a variety of stakeholders.’

He adds: ‘Email volume has definitely gone up because so many different bodies want some of the clinical director’s time.’ All this extra work on directors, who are often GP partners, has a knock-on effect on GP practices, who are also grappling with the bureaucracy involved in being a part of networks themselves.

Yet despite these teething problems, there have been upsides. Dr Farzana Hussain, clinical director of Newham Central 1 PCN, in east London, says: ‘PCNs have given our seven practices a real opportunity for shared learning and quality.

‘This year, our practices had their first telephone annual review from the CQC. We were able to share experiences, learn from each other and have an honest dialogue that we’ve been unable to have before now. Pooling our knowledge is powerful.

‘We have also discussed emergency department attendance and found common themes we can work on to reduce it. That has definitely reduced variation in quality of general practice and improved patient care.’

In terms of the teething problems, NHS England says it wants to be informed of instances where a CCG is refusing to release funds, so it can ‘resolve’ them. It says some areas are experiencing increased workload, but ‘ultimately the direction of PCNs is to alleviate pressure’. Meanwhile, they are increasing digital infrastructure support to share across networks.

Dr Kanani tells Pulse: ‘It is crucial we continue to reduce bureaucracy for primary care, ensuring networks build strong local relationships and can easily access development, and are supported to recruit the additional staff to improve patient care for now and the future.’

Next year will be the real litmus test, however. From April, all networks must begin to fulfil seven service specifications under the network DES. These are: medications reviews; enhanced health in care homes; anticipatory care for high-need patients; ‘personalised care’, to implement the NHS Comprehensive Model; early cancer diagnosis; CVD prevention and diagnosis; and tackling neighbourhood inequalities.

NHS England says networks that deliver these ‘further’ and ‘faster’ will get additional funding.

But the biggest fear, as always, concerns workload, when GPs already operate in a system under immense pressure.

Wyre Forest Health Partnership PCN chair Dr Roy Williams says: ‘I believe in PCNs but the expectation that we can deliver the national specifications using the additional roles funding alone is flawed in my view.

‘I feel we have been missold. Really struggling to understand the thinking that the few hours of additional staff we’re paying 30% of will allow us to suddenly deliver five national specifications – this should be about making practices sustainable first.’

Large network: ‘Professionals want to be part of a large, well-supported team’

Name of network Enfield Unity

Population 158,030

Member practices 23

Clinical directors Dr Ujjal Sarkar, Dr Sarit Ghosh and Dr Chimere Aka

Enfield Unity comprises a super partnership of 14 practices, known as Medicus Health Partners (MHP) as lead network practice, along with nine other practices.

We have notionally split the network into three neighbourhoods to match the differences in patient population. The west of the borough has an older and affluent population while the east has areas of significant deprivation.

The formation of the PCN for us has been about reassuring new practices that their voices are heard and the advantages of MHP’s centralised governance, finance and HR services.

We have spent time getting the basics right so practices know where they stand and we have a solid foundation. This has included specialist legal, HR and data support, robust financial modelling and consultation with a VAT specialist.

Our attractiveness as an employer for the new roles is enhanced as they often want to be part of a large, well-supported team. In time I’m sure we’ll see benefits in terms of service delivery and system resilience.

Smaller network: ‘As clinical director, I can’t do it alone’

Name Wokingham West

Population 29,617

Member practices 2

Clinical director Dr Amit Sharma

We are a three-site practice – my practice has 27,500 patients, almost a network in itself; the other one has just over 2,000 patients and it is the closest geographically to us.

Previously, we were in a cluster with two other practices, which are much larger but the geography was very large – there wasn’t really a natural community and it was much more rural. The demographics of our two practices is very similar and our vision is very similar so it made sense to work together.

The benefits of having a smaller PCN is that you get a much more local feel and the services are more owned, and close to the patient. It’s really important to make sure you don’t lose touch with the patient.

There is the challenge of having enough time to do all this PCN work while running two busy practices. All this work has come additionally so you’re left in a position where you need to put more hours in or obtain new staff.

With the best will in the world, as clinical director, I can’t do it alone. I’m fortunate to have a great team but I know that team is already stretched so it’s a real challenge.

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