‘Twas two nights before Christmas. But instead of winding down for the festive period, officials at NHS England dropped a bombshell of a document – the proposed responsibilities that primary care networks would take on from April.
Its repercussions have already been profound. They have derailed contract negotiations between the BMA’s GP Committee and NHS England, and led the BMA to call a ‘special LMCs conference’.
The proposed specifications at a glance – Structured medicine reviews
• Every six months identify patients who need SMRs, including those with complex polypharmacy, those prescribed medicines associated with medication errors and those with multiple long-term conditions.
• Offer SMRs to all identified patients
• CCGs will review variations in the number of SMRs undertaken
• Develop local processes for reactive referrals
• Develop PCN plans to reduce inappropriate prescribing
More importantly, they have severely shaken GPs’ faith in the whole PCN project, barely a year after it was started.
Among the proposed specifications for PCNs was the requirement for a suitable clinician to do a weekly round at care homes. At least every two weeks, this would have to be a GP – or a ‘community geriatrician’, if one can be found. Others included structured medicine reviews, ‘anticipatory’ and ‘personalised’ care and a greater role in early cancer diagnosis.
There were also indications of hidden dangers ahead: a hint that PCNs will be responsible for out-of-hours care, and of the return of the unplanned admissions DES requirement to plan individual care for increasing numbers of patients.
• Build comprehensive and dynamic list of individuals who would benefit from anticipatory care, including those who have complex needs and are at high risk of unwarranted health outcomes
• Establish comprehensive support for those individuals
• Offer medicines optimisation, social prescribing, carer identification and signposting to local support
The fallout was swift. A number of LMCs advised practices to refuse to sign the DES in 2020. Several PCN clinical directors resigned as a result (see Opinion, page 24). A Pulse survey revealed 80% of partners in England wanted their practice to ditch the DES.
Following the GPC’s decision to reject the contract on the table, chair Dr Richard Vautrey said: ‘NHS England was overwhelmed with feedback, which was unanimous in its condemnation.
‘We have a clear mandate from our colleagues, to negotiate a deal that truly benefits and safeguards general practice, family doctors and their patients.’
As Pulse went to press, the two parties were still in negotiations. But the early signs were that NHS England realised the document was a serious error.
In closing the consultation, it struck a contrite note: ‘Having invited your feedback, we want to be absolutely clear that we have heard the views expressed. We will now carefully consider how to respond adequately, balancing the ambition to improve services for patients and the need to stabilise general practice, with what can realistically be delivered by PCNs in 2020/21.’
But, even if NHS England does row back on its proposals, for many GPs the document served to reaffirm concerns many had at the start of the PCN project.
In a sense, NHS England’s position was clear from the start. The original GP contract in early 2019 stated networks would have to focus on ‘more intensive’ support for care home patients, and funding for additional roles would be linked to the final specifications.
This was buried amid the fanfare of the new contract last winter. It was made clear to practices that networks were the future. A huge proportion of the £4.5bn of extra funding going into primary care – and even some existing funding – would go to PCNs. The biggest incentive for practices and networks was the Additional Roles Reimbursement (ARR), scheme, which provided funding for pharmacists, social prescribers and, in future years, physician associates, paramedics and physiotherapists.
• Conduct a weekly home round for registered patients led by a ‘suitable clinician’. At least every other week, this should a GP or a community geriatrician
• Coordinate delivery of a personalised care and support plan with people living in care homes within seven days of admission. Refresh plan at least annually
• NHS England to consider ‘how to bring out-of-hours provision under PCN authority, to ensure more effective and coordinated support’
There was also an incentive of £2 per patient for practices that sign up to the new Network DES. Considering the global sum uplift was a mere 90p per patient, for most practices there was little choice but to sign up, and 99% did.
Yet the service specifications have led many to feel it is simply not worth it. A document produced by Berkshire, Buckinghamshire and Oxfordshire LMCs estimated member practices faced a £100k deficit from these proposals.
It points out that structured medicine reviews alone could involve 20% of registered patients: ‘If each SMR takes 30 mins of total GP time, this equates to an extra 1,000 hours per year… 24 sessions per week for a PCN of 50k patients.’
‘Someone at NHS England has failed to grasp what is going on in PCN land’ – Dr John Allingham
On care homes it said: ‘The Government’s own figures cite 410,000 people as resident in care homes in England… an average of 56 people per practice. If each patient needs a weekly review, this is a minimum of 20 mins per patient… This comes to about 18 hours of clinical time per week, or 4.5 sessions.’
Other GP leaders point out that the staff on offer are nowhere near enough to fulfil the requirements. Dr Jonathan Harte, clinical director of Bachs PCN in Nottingham, says: ‘The suggestion is that clinicians doing medication reviews are experienced and prescribers. A lot of the clinical pharmacists being recruited aren’t prescribers yet. So, who’ll sign off changes or support significant training needs? GPs. Again without funding.’
The strength of opposition to the proposed requirements led LMCs – including Berkshire, Buckinghamshire and Oxfordshire – to begin advising practices to ditch the DES.
• Personalised care and support plans must be in place for at least 5-10:1,000 of the weighted population, including those in the last 12 months of life and in the anticipatory care and care home cohorts. This will increase in steps to reach 20-25:1,000 by 2023/24
• Promote personal health budgets.
• A target for social prescribing referrals of 4-8:1,000 weighted population in 2020/21, rising to 16-22:1,000 in 2023/24.
Birmingham LMC secretary Dr Robert Morley tells Pulse: ‘We believe the only way the required changes will be made is if practices signal en masse their intention to withdraw from the DES.’
Perhaps even more importantly, PCN clinical directors began to distance themselves from the proposals. The clinical directors of the four Guildford and Waverley networks said the draft service specifications under the contract would degrade general practice and called on all member practices to ‘withdraw from the PCN DES entirely’ unless there was ‘significant alteration’.
‘The usual negotiations will not solve this catastrophic state of affairs’ – Dr Robert Morley
But even with the contrition shown by NHS England, for some GPs the proposed specifications showed the way managers want to go – and this doesn’t bode well for the contract or the future of networks.
As the Berkshire, Buckinghamshire and Oxfordshire LMCs document concluded: ‘The LMC cannot in any way endorse these specifications, nor do we have any confidence that national negotiations will result in NHS England agreeing to sufficient positive changes.’
Birmingham LMC concurs. ‘We do not believe the usual processes of negotiation by the GPC will resolve this catastrophic state of affairs,’ Dr Morley says.
Supporting early cancer diagnosis
• Improve referrals, using data to explore local patterns in presentation and diagnosis
• Introduce a consistent approach to monitoring patients who have been referred urgently with suspected cancer – ‘safety netting’
• Networks will be measured by the proportion of cancers diagnosed at an early stage and the increased uptake of national screening programmes
Kent LMC medical secretary Dr John Allingham tells Pulse: ‘Somebody at NHS England has completely failed to grasp what is going on in PCN land. There’s obviously a belief that since we formed PCNs, we miraculously created a lot of additional capacity, but we haven’t. And there’s also a belief GPs can deliver miracles on £1.50 per patient. The funding needed is vastly in excess of that to go anywhere near delivering anything.
‘There is a possibility that, having started a negotiation with such a ridiculous assumption, when they run back from it we’ll think we’ve got something manageable. So the specifications will go from impossible to just bloody difficult, and we’ll accept it.’
Or maybe not, given the current strength of feeling towards the whole PCN project.
What can practices expect next?
What is next in terms of finding out about the requirements?
We’re awaiting negotiations between the BMA and NHS England. These are holding up important work with our populations because services, such as a local enhanced service for care homes, may potentially be pulled.
We’re also having to alter plans for future Additional Roles Reimbursement (ARR) scheme. For example, if the structured medication review isn’t radically adapted on the specification, we’ll need more pharmacists at the expense of a physiotherapist, as the DES specification workload involved in SMRs is so high.
PCNs are just over six months old and at a stage where early relationships are forming between practices, but this has created a standstill and uncertainty. We just hope it doesn’t take us six months backwards.
What are the implications if you as an individual or practice don’t want to sign up?
Patients lose out on the ARR work that benefits the practice, such as networks’ ambitions for pharmacists to make repeat prescribing and hospital discharge medicines reconciliation safer and more efficient, and to reduce GP workload.
Similarly, the practice loses out on the link worker, who could reduce a GP consultations by a quarter.
Patients would need to be served by other practices in the network, creating additional pressure. Meanwhile, both the organisation of patients and additional roles of the services must be considered, such as where exactly the patients will be seen and who will do the admin.
As the other practices in the network will have to pay the 30% costs, there may be implications for how the practices in the network that are signed up to the DES get work done for this extra cost. Why would the rest of the practices footing 30% of the bill help the one that opted out with tasks such as repeat prescribing, and how will it be cost-effective for those signed up?
If a partner doesn’t want to sign up but their practice does, how can this be resolved?
There is no obvious answer. Internal practice negotiations would be needed. It may be that this will need to go to a vote. You would have to decide whether to include salaried GPs but do take their views into account. If you are a two-partner practice, remediation might be required.
I would hope partners aren’t forced to resign or retire early, and that practices aren’t rocked by this.
Dr Farzana Hussain is clinical director of Newham Central 1 PCN and a GP in east London