Primary Care Networks are gathering pace. From April 2020, they enter a new phase with additional service requirements and a wider workforce. CCGs will hold them to account. This article explores the issues and impact the changes may have on CCGs.
What's the new deal?
The five year framework for GP contract reform, published in 2019, established the role of Primary Care Networks (PCNs) . Approximately 1250 PCNs now cover virtually all of England.
The five year framework discussed multiple services being provided by PCNs by 2024. The first year of PCNs focused on establishment and development as GP practices got to grips with new workforce and financial arrangements. The focus now moves to delivering new services.
In December 2019, NHS England consulted on five new service specifications for PCNs to be delivered from 1 April 2020. They were all or nothing – PCNs could not choose which services to deliver. Stakeholders including GPs, PCNs and LMCs voiced increasingly loud concerns relating to workforce implications, the level of resource available to support delivery, the level of specificity, the length of the specifications and the aggregate effect of introducing all five services from April.
There were calls from LMCs for practices to pull out or not sign up to the new arrangements. This culminated in the BMA's GPC, acting on behalf of GP practices, rejecting the entire GP contract offer for 2020/21 including the five new PCN service requirements.
NHS England responded by making significant changes to the service specifications. On 6 February 2020, NHS England reached agreement with the GPC and published the new deal. The main change is the removal of two of the services, leaving three to be provided in 2020 and the rest set to be introduced in 2021.
Three new PCN services
PCNs signing up to the new deal will be required to deliver the following services:
- Structured Medication Review and Medicines Optimisation;
- Enhanced Health in Care Homes; and
- Supporting Early Cancer Diagnosis.
The service specifications have been significantly reduced in length. Targets are now more locally focused. For example, the number of structured medication reviews a PCN must provide will be determined by the clinical pharmacist capacity of a PCN. Workload pressures have been addressed by no longer requiring GPs to carry out certain activities. For example, concerns had been expressed at the requirement for a GP as part of the Enhanced Health in Care Homes service to carry out fortnightly face to face medical consultations with care home residents. The care home resident consultations now require medical input to be 'appropriate and consistent' with the frequency and form to be based on local clinical judgement by the PCN.
What does this mean for CCGs?
CCGs play a vital role in ensuring PCNs provide safe and effective services. They approve PCNs, they support PCNs and they hold them to their contracts.
At the time of writing, no PCNs are separate legal entities. It is foreseeable that a PCN could request to incorporate its collaboration of practices' GP contracts but implications for the survival of individual practices means that such requests are likely some way off. At present, requirements of a PCN are requirements of each GP practice member. A CCG must therefore hold individual practices responsible for a PCN's compliance with its obligations.
Contract management of PCNs
This can raise novel issues for CCGs in applying GP contract management processes to PCNs such as issuing breach notices or withholding payments. So far, we are unaware of any formal disputes between PCNs and CCGs (for example, there are no PCN groups of individual practices which have had a dispute determined and published by NHS Resolution's Primary Care Appeals (PCA) unit which is where we might expect to see such issues.) The increase in PCN service requirements and financial entitlements could result in increasing numbers of disputes. CCGs should keep an eye out for how the PCA might approach these matters.
PCNs are currently grappling with employment models for their additional workforce. Recent changes to IR35 rules, complex tax arrangements and the expectation that PCNs will recruit for significantly more roles means PCNs are seeking legal and financial advice on how best to organise themselves. A PCN's Network Agreement should capture the workforce arrangements and make clear how employment and tax liabilities are managed. Although the Network Agreement is largely outside the scope of a CCG's role in relation to PCNs, we are increasingly seeing PCNs approach their CCG for assistance in obtaining professional advice.
Expectation of CCG support
Indeed the new deal document states that CCGs and Integrated Care Systems are expected to explore different ways of supporting PCNs including by offering support from their own staff to help with co-ordinating and running recruitment exercises, offering collective/batch recruitment across PCNs, brokering arrangements to support full-time direct employment of staff by community partners and ensuring that NHS workforce plans for the local system are as helpful as possible in meeting PCN intentions.
The Network Contract DES Specification for 2020/21, once published, will contain the full range of service requirements and financial entitlements of a PCN. CCGs will need to carefully consider contract management, particularly in relation to the three new services. The changes made to assure acceptance of the service specifications could challenge CCGs' traditional approach to contract management.
How does a CCG assess whether a specific volume of structured medicine reviews is right where that volume is determined by the PCN based on the capacity of the PCN's clinical pharmacist(s)? Does a CCG second guess the local clinical judgement of a PCN as to what the appropriate frequency and form of care home resident consultations, and whether the provided medical input is 'appropriate and consistent'?
As the extent of service delivery by PCNs increases, CCGs will need to be alive to guidance on how to ensure both the safe and effective provision of PCN services and the application of robust contract management approaches.