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It is not difficult to find hyperbole when it comes to the announcement of health service reforms. It was not long ago that the changes introduced by the then health secretary Andrew Lansley were described by the chief executive of the NHS as being ‘so big that they are visible from space’, and according to the previous RCGP chair, the GP Forward View was heralded as the most significant opportunity for general practice for 40 years. Perhaps this should not surprise us given the thousands of people working in NHS offices up and down the country, spending their careers trying to improve efficiency in a system which is widely regarded as grossly under-resourced, overstretched and mired in bureaucracy and micromanagement. To misquote Oscar Wilde, perhaps the ability of the NHS to announce with great celebration further reforms in the hope of saving the NHS should be regarded as a triumph of optimism over experience.
And yet perhaps the changes to the 2019 GP contract might one day be looked back upon as the most significant change to the structure and provision of primary care in a generation. The formation of primary care networks represents an entirely new way to commission some functions of general practice.
Their inception is certainly a reflection of the current unique set of circumstances which we find ourselves in. Since 2004, many in the Department of Health (and now Social Care) and Treasury have been reluctant to invest significant new sums in our GMS contract, claiming that there is little way of demonstrating value for money. On the one hand there is often an acknowledgement of the strength in efficiency and entrepreneurship of the independent contractor status, and yet there is also a perception that GPs work to increase profits when spend on expenses and levels of investment in staff is not necessarily clear to commissioners.
It is also seen by commissioners as something of a challenge, to have to deal with and monitor so many different providers of the service. For the last 15 years the annual contract negotiations have often been difficult, with GP negotiators seeking increased resources for practices, and NHS Employers attempting to wrest yet more efficiency gains from GPs at minimum cost.
While frequently describing general practice as the foundation of the NHS, the Department of Health has presided over a period of crisis in the recruitment and retention of GPs, especially as partners.
There is some satisfaction on both sides of the negotiations that perhaps finally a way has been found to secure significant additional investment in general practice. For reasons which are clear, this is not achieved simply through uplifts to core GMS, but rather through a non-core, voluntary enhanced service. GPC and LMCs are encouraging practices to collaborate to develop the vehicles to allow these funds to flow and to enable the appointment of a pharmacist and social prescriber in the first instance, with the promise of more ‘boots on the ground’ in future years. Meanwhile CCGs are mandated by the Department to achieve 100% network coverage, and incidentally in one fell swoop to deliver for the first time universal extended hours, since this is a requirement of the DES.
Yet the perception of these fledgling networks is rather different depending on who is describing their potential future role.
For some in NHSE and CCGs, networks provide the possibility of commissioning a new breed of provider organisation, with the potential to deploy them as the building blocks of a wider integrated care system. There is already talk of PCNs having responsibilities for budgets, delivering on targets and committing to achieve outcomes defined by CCGs. Finally, some would say, GPs might have ‘skin in the game’ when it comes to reducing admissions and spend in expensive secondary care environments. There are GPs who also subscribe to such ideas and embrace the challenge.
An alternative view is that networks are a way to bring long overdue resource to perhaps assuage the worst crisis in general practice for decades. This sees networks as a way to empower general practice to start to take control of an expanded primary care workforce, to make the work sustainable and perhaps prevent the further haemorrhage of doctors who are finding the burden of working in the current environment unmanageable. It is a risk that a shrinking number of last-GPs-standing simply get used to the current unsustainable and impossible workload, in such a state of exhaustion that we no longer have the energy to resist. The ability to secure partial funding for more staff to support practices might eventually decrease workload, enhance team working and improve morale, retention and recruitment in the profession, but there is much work to be done. These resources are ours. These staff are to support our workload, not to solve wider system problems. This is self-evident not least because we are contributing to their costs and carry full responsibility for their terms of employment.
So, it is difficult to entirely predict where things will go with PCNs. It is possible there may be a ‘sweet point’, where they are able to fulfil the needs of the development of general practice over the next decade as well as delivering improvements for the system as a whole. If general practice works well, the NHS works well.
However, this is reliant on PCNs developing at pace and with the full commitment and engagement of the profession. There are significant challenges. VAT liability and pension rights for employed staff are relatively small hurdles to overcome. Much more important is the urgent need to address the unique liabilities of GPs as providers and to explore new legal structures that will permit GPs to take on risks of increasing numbers of employed staff, as well as engaging with newly commissioned services. There was a call three months ago by the author of the GP partnership review for this work to be completed in six months. It would be unwise for NHSE and CCGs to assume that GPs might be willing to expose themselves to unique levels of risk, in a system which frequently fails to achieve financial balance unless there is a reduction in liability. If GPs are pressured to take on too much risk or to deliver outcomes based on investment in PCNs, the promised renaissance for general practice working at scale will never flourish.
There may be some cause for optimism, but the future of PCNs will very much depend on the ability of our negotiators to achieve success in further PCN negotiations, in limiting liability and avoiding a sleep walk into becoming an instrument of an ICS, as well as GP members of PCNs always remaining mindful that they are engaging in a voluntary DES, and that its primary purpose should be to support and sustain general practice. The future must be in our hands. So long as PCNs serve the interests of general practice and our patients, there is reason to be in the game. If there is reason to believe we may lose our skin, then we must always reserve the right to walk away.
"in one fell swoop to deliver for the first time universal extended hours, since this is a requirement of the DES."
So , GPs are working longer and more unsocial hours for minimal pay - where is the 'long-overdue resource"?
Thank you for that information you article
Good article- thanks. There is no need to 'walk away'- just don't sign up !
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Too long as state quasi-employees has left GP Partners looking very foolish, skipping gaily into PCN's which to anyone with an ounce of business nouse look more like dangerous cliff edges than a place of "safety in numbers". More liability and more risk with no prospect of more reward? Extended hours with no added funds for proper clinicians? "Partial funding" for additional staff which they must employ?
Finally, and most importantly, if GP partners in PCN's take on health budgets they will be at severe risk. Most CCG budgets in the country are in or are near deficit. We currently live in a world in which there is ever increasing pressure on GPs to investigate symptoms earlier and more extensively than ever before - viz. the recent "65% of cancers missed by GPs" quotes in the papers). This will blow most health budgets out of the water - together with the GP Partners who have been sucked into owning PCN's...
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The collapse of practices is proving a liability to NHS England - so they have decided to band GPs together in a collective responsibility for providing services. If one practice in the PCN goes under, the others have to absorb the work and responsibility. Never mind that at scale GP services reduces continuity, reduces patient satisfaction, and there is no evidence to suggest it improves patient outcomes. This is a cowards answer to an unmanageable, burgeoning workload. NHS England need to reduce demand (this will involve charging patients). Again GPs are being given a workload dump, albeit dressed up as ‘system transformation’.
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