GPs are only just beginning to understand what it will mean to be part of a primary care network when their practices come to join one in the next few months.
When the new five-year GP contract was announced by NHS England and the BMA in January, networks were the centrepiece, with financial incentives offered to encourage practices to join.
The new ‘Network DES’, to be paid directly to networks serving between 30,000 and 50,000 patients, was unveiled – and a deadline of 15 May was set for networks to have submitted their registration information to CCGs.
The guidance stresses it should be GP practices – and not CCGs – that decide the geographical area their network covers.
It says the ‘only involvement of the CCG in this process should be when there are gaps in the total primary care network (PCN) coverage of their area’.
In that case, ‘the CCG, in collaboration with the relevant LMC(s), should act as liaison between the proposed PCN groupings in the area and the practices that are not currently included in any such grouping, either by choice of the practice or the PCN’.
The handbook also clearly states the network agreement – outlining how the PCN will operate and what services it will provide – ‘is not within the remit of the CCG to challenge’.
‘As long as the practices have agreed, the CCG cannot refuse the DES based on its content,’ it adds.
However, Pulse has learned that, despite the understanding that GPs should be leading the formation of network, CCGs in some areas of England have been trying to ‘manipulate’ new primary care networks to ensure they align with their own plans.
The BMA’s GP Committee executive team member Dr Farah Jameel said the BMA had heard of ‘CCGs telling primary care networks who their clinical directors should be, and CCGs telling primary care networks what their geography and boundaries should be in order to align with local community teams’.
The BMA handbook explains networks can be structured in a number of different ways, citing five possible models:
- Flat practice network – responsibilities, contractual commitments (including the employment of additional workforce) and funding are spread between members instead of being fronted by a lead practice
- Lead provider – a single practice is the focal point for securing additional workforce and entering additional contractual arrangements on behalf of the PCN.
- GP federation/provider entity – the federation/provider is subcontracted to deliver services required by the DES, and employ the range of staff necessary to do so. The DES funding would be paid to the member practices and then be passed on to the federation
- Super-practice as a network – the super-practice would need to create an internal set of mini networks. The super-practice would be the nominated payee and would then supply resources to its mini networks. From 2020/21 it is expected that another health body would need to join the super-practice to qualify as a network.
- Non-GP provider employer models – in which practices ally themselves with another local healthcare provider – such as a community trust, which through signing up to the network agreement alongside the GP practices can provide network-level services on behalf of the PCN.
Appointing an accountable clinical director
The BMA’s guidance suggests the clinical director can be selected through a normal appointment process. Candidates from practices within the network would apply for the role, a selection panel would be convened and a collective decision made on who to appoint.
Alternatively, it proposes that practices could select the clinical director by election. This would involve inviting expressions of interest and candidates submitting personal statements, before the constituted network board – or all partners in the network – hold the election.
Despite it being previously understood that GPs would be the only candidates for the clinical director role, NHS England’s acting director of primary care Dr Nikita Kanani has recently clarified that ‘any clinician’ in general practice will be able to take charge.
The BMA has also confirmed to Pulse ‘if the network prefers another clinician, who has the necessary skills, then they are free to appoint them too’.
Setting up a governing body
The guidance advises practices to set out a clear decision-making process for the network. This should identify the relevant people acting on behalf of network members – for example, one representative from each practice, a selection of individuals from across the network, all partners from each practice – and the weighting of votes.
The BMA suggest a network may have a board including one representative from each member practice – or perhaps all partners from each practice, in which each group of partners have a vote share in line with their respective practice list size.
Meanwhile, if there any disagreements between practices in a network, the guidance states there should be ‘clear dispute resolution procedures in place’ and advises ‘the network draws on the relevant LMC as an independent mediator in such processes.’
The guidance highlights that practices will need to consider HR issues relating to the new expanded workforce the network will receive as DES funding increases and new roles are brought in
To address this, practices could consider limited liability structures, or sharing liabilities equitably across members of the network.
The handbook also warns healthcare staff hired by the network may encounter problems accessing the NHS pension scheme, depending on the network structure.
To have access to the scheme, the employing body must hold an NHS contract. For networks operating under a ‘lead employer’ or ‘flat practice’ model this will not be an issue.
But if the PCN is set up under a limited liability structure – such as a GP federation – the staff employed by that body under the DES may not be able to access the NHS pension scheme, according to the guidance.
The BMA says the issue is ‘currently under discussion with NHS England, and we are hopeful of a resolution in the near future’. But it warns that ‘practices should be aware that any agreed changes to the access arrangements for the NHS pension scheme are unlikely to be in place in time for July 2019’.
The BMA’s handbook warns that the network structure could lead to inadvertent VAT charges – because while healthcare services are exempt from the taxation, the provision of healthcare and back-office staff is not.
It says practices therefore need to ensure their chosen network structure cannot be interpreted in a way that means they will attract VAT.
‘The BMA and NHS England are investigating this issue and will provide guidance as soon as possible. However, we strongly recommend that networks take advice on their specific proposals in order to fully safeguard themselves in the future,’ it says.
When the new contract was announced, GPs were told the Network DES money would incorporate funding for new staff – including social prescribers and pharmacists – and a transfer of extended access funding. Plus a payment of 59p per patient to cover leadership of the network. Meanwhile, networks would separately receive an additional £1.50 per patient through ring-fenced CCG funding.
But since then Pulse has learned that under the new Network DES, funding for extended hours will be reduced – with networks being paid £1.45 per patient, which is 45p less than practices currently receive.
Meanwhile, our analysis of BMA figures laying out the overall funding on offer to networks has found those serving 30,000 patients will be in a more financially advantageous position – receiving around £1 per patient more than 50,000-patient networks in 2019/20.
Networks with 30,000 patients will receive around £4.59 – compared with £3.62 for networks with 50,000 patients – because all networks will receive the same amount of funding for pharmacists and social prescribers in their first years, regardless of size.