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PCNs have been tasked with a new focus following the update to the GP contract. And that’s before the publication of the NHS primary care recovery plan, which may bring even more change. In the first of two features, Emma Wilkinson looks at how PCNs are reacting to the situation
In the update to the GP contract in England at the end of March, Primary Care Networks (PCNs) faced more change. They had spent the past year trying to get across the Impact and Investment Fund (IIF) and had just battled through a winter of extreme pressures on the health service when they were asked to switch focus once more.
Under the IIF part of the Network DES, PCNs will be given an average of £3 per patient – up front – in 2023/24 to help support them to improve access. It works out at about £11,500 per month for an average PCN.
They have also been tasked with putting forward plans to improve access for approval to receive a share of a further £74m – around £60,000 per PCN per year. Initially given just six weeks, this deadline has now been extended to the end of June.
To receive the additional £1.30 a patient, PCNs will also need to show improvement in the patient experience over the year through metrics such as the patient survey and the friends and family test, adopt cloud-based telephony systems, and accurately record data.
A separate IIF indicator sets a requirement of 85% of patients being given an appointment within two weeks of requesting one. That is worth about £14,000 per PCN, but GP negotiators have advised GPs and networks to ignore it given its low value.
There were mixed responses from PCNs hearing that the deadline had been moved back another seven weeks. Dr Laura Mount, clinical director at Central and West Warrington PCN, says that the initial date of 12 May had been very tight, especially because it takes time to get agreement across several practices. But most of the work had already been done by the time the delayed date was announced.
‘We had done quite a lot of work, and what always happens is they delay it, and then they want more information and more detail, and we would have preferred just to submit it, to be honest,’ says Dr Mount.
Dr Emma Rowley-Conwy, clinical director at Streatham PCN in London, says the original deadline had been too early, and they had received no guidance.
She is currently looking at all possible solutions, including GP duty doctor triage, doctor first for everything and AccuRx triage. She plans to come up with a shortlist of options to present to member practices. ‘We have monies up front, which is good, so potentially we can buy in consultancy or resource to help lead this work for us.’
Locally the PCN clinical directors (CDs) agreed that a ‘quick win’ is just to improve data collection and log every single patient contact, she adds.
Dr Douglas Price, CD at Burntwood PCN in Staffordshire, says the extra time is helpful for reasons beyond simply having more time to put a plan together. The one thing missing in all this, he notes, is the long-awaited NHS England primary care recovery plan.
‘Maybe the delay is because the general practice recovery plan is coming out soon, and the plans will be more meaningful if there is meaningful money to spend in that. We live in hope,’ he adds.
In general, Dr Price has mixed feelings about the contract update for 2023/24, which is, in essence, just repurposed IIF funding.
Yet he is happy to see the high number of IIF indicators being reduced, which appears to be in line with the philosophy of the recent Hewitt review conclusions on reducing excessive targets while maintaining accountability.
‘I think we are likely to try and hit the targets to achieve the 30% of the local capacity and access improvement payments that are not guaranteed. However, if we weren’t able to achieve this, it wouldn’t be the end of the world as the 70% guaranteed payment may be broadly similar to our current income.’
Change to triage model
Regarding the access plan, their integrated care board (ICB) do seem to understand the pressures general practice is under. However, the situation at his practice is reflected all around the country. They have always aimed for a two-week routine appointment but hitting that has become harder. All their PCN practices already use cloud-based telephony – Dr Price’s practice put it in place three years ago. In addition, they have expanded their team as much as they can. And they already have a large urgent care team.
‘I suspect that what will happen is, over time, we will be forced into moving to a total triage model, something we’ve been reluctant to consider so far as we fear it will change the nature of the job into something that many of us as doctors don’t want to do.’
He adds for some practices with the 8am rush to get an appointment, there may be new models to try. But equally, he believes there will be plenty of practices that feel they are behind the times for not having total triage.
‘I think the imposition of the contract feels demoralising as a partner. If the BMA had negotiated the exact same contract with the same issues, at least I would have felt that we had some input into what’s going on. And psychologically, it’s easier to push for a vision of what general practice can be if you feel engaged in the process,’ he says.
Dr Tom Holdsworth, clinical director of Townships 1 Network in Sheffield, says the NHS is creaking under demand, and that cannot be fixed with a few extra appointments even if the staff were available. Yet on the flip side, there is an opportunity for PCNs to think laterally.
‘Most of the money has been paid upfront on a monthly basis without any particular asks. For me, it is a chance to provide a little bit of headroom to try some things and see what makes a difference.
‘I’m going to encourage the PCN to think about what are the drivers of demands that may be in our control and see what we can do about them,’ he says. ‘That first plan is unlikely to be the fully detailed final version but provide a sense of where you intend to focus your efforts.’
He adds: ‘I’d be thinking about high-intensity users and could we do something around identifying those people and looking at what our MDT team could do to support them.’
Dr Holdsworth adds that patient experience around booking is another area to look at. For example, this could mean providing other ways to book routine nurse appointments or a different approach to organising triage. This would include looking at scale and learning from practices that have done the most work on these aspects already.
It is not necessarily the plan itself – which initially is likely to be fairly broad brush – that is the worry, says Dr Holdsworth. Instead, the challenge is getting practices to engage with it after it is approved, given the amount of exhaustion and change fatigue.
‘The feeling is that people are already working as hard as they can – that will probably make it more difficult to get the engagement of all the practices to make progress,’ he says.
Dr Holdsworth points to the report published in April by The King’s Fund on the rise and decline of the NHS over the past two decades. Written by Professor Sir Chris Ham – and somewhat missed by the mainstream media amongst strikes and other policy papers – it was, he says, ‘utterly damning’.
‘Policy direction and rhetoric for the last 10 plus years has been care closer to home, more care in the community, and funding and resources have flowed the other way. The resource has been stripped out of primary care and community services, so it’s no wonder people are struggling. A year’s worth of additional funding for access is not going to be a silver bullet,’ he says.
Dr Holdsworth says it comes back to the same problem PCNs have always faced. That is piecemeal budgets with ever-moving goalposts.
‘Someone described it to me as a whole load of different safes with different keys and having to find the right key to unlock each bit.’