Monthly Archives: July 2019

How will the money flow into PCNs?

Now we have confirmation that the vast majority of practices (99.5% according to NHSE) have signed network agreements and are therefore part of a PCN, it is timely to see how the money will flow. The promise is for a lot of new funding that will help transform General Practice – NHS England has calculated that by 2023/24 a typical network covering 50,000 people will receive up to £1.47m via the network contract. Are there catches though? And what does it mean for individual practices?

What is the money for?

The new funding is tied closely into delivery of the goals set out in the NHS long term plan and this will involve moving more services and treatments for patients into a primary care setting and a lot of these services will fall under the auspices of GPs. PCNs will have responsibility for delivering seven national service specifications set out in the contract, namely:


• Structured medicines review and optimisation (2020/1).
• Enhanced health in care homes (2020/1).
• Anticipatory care (2020/1).
• Personalised care (2020/1).
• Supporting early cancer diagnosis (2020/1).
• Cardiovascular disease prevention and diagnosis (2021/2).
• Tackling neighbourhood inequalities (2021/2).


We will return to consider these in more detail but for now it should be obvious to GPs that this is not a give-away and NHSE is looking for its pound of flesh. Full details of the seven service requirements are yet to be published, but PCNs will be expected to deliver against an agreed set of ‘standard national processes, metrics and expected quantified benefits for patients’. The devil will be in the detail no doubt. For the current year, formation of PCNs is the goal but 5 of the 7 services will be commissioned from 2020/1. Time to make ready and get as much of the detail as possible.

In order to give GPs a chance to provide these new services, there is an acceptance that new staff will likely be required and hence the Additional Roles Reimbursement Scheme which is supposed to help pay for 5 new roles:


• Clinical pharmacists;
• Social prescribing link workers;
• Physician associates;
• First contact physiotherapists;
• First contact community paramedics.


Again we will return to discuss these roles in more detail but for now suffice to say that this is a reimbursement scheme and not money up front and the reimbursement level is not set at 100% of costs (apart from social prescribing roles) so technically these roles will be a cost to GPs.


The money

£1.8bn of the extra £2.8bn promised additional funding for general practice will flow through the Network Contract over 5 years. Once again, the devil is in the detail; money will increasingly flow to the PCN and not practices:

 Practice                                                  PCN
 £1.76    Network Participation           £0.51  CD Role
-£1.90   Extended Hours                     £1.50  Core PCN

                                                             £1.45   Extended Hours

-£0.14    Total                                      £3.46  Total

This is fairly simple arithmetic, but the point is worth making. Practice income will go down. Note the comments above about the ARRS monies as well; those PCNs that choose to employ extra staff will have to decide which practice acts as the employer and technically this practice will see another deficit (because the reimbursement level is not a universal 100%). How the difference will be made up has not been dealt with and could prove a tricky issue in the early days of PCN formation.

The conclusion is that GPs should not assume that, having joined a PCN as mandated, money will now flow to them directly. Increasingly the money will flow directly to the PCN and this means that GPs will need to have arrangements in place for both managing this and for governance purposes. While it I true that practices in England have increased the level of collaboration in recent years, this really is something new. The stakes have been raised because co-operation no longer relies on simple goodwill and instead has a significant monetary component. The new services will further test the level of co-operation because they will need to be provided collectively if they are going to operate efficiently. If this is the ‘storming and norming’ phase, then there is much to be done.

Will NHS Resolution provide the answers to GP indemnity issues?

One of the changes that the new GP contract framework brings is that NHS Resolution will provide indemnity cover for GPs henceforth. Given indemnity provision is a real cost to partnerships, this should be a good thing and will release not insubstantial amounts of money. However, the devil is always in the detail in these things and we examine some of the details here. First question is ‘what is NHS Resolution?’. It is part of the Department of Health but operates at arm’s length and was formerly NHS Litigation Authority which gives a clue about why it was created. It has operated as the negligence claims authority since 1995 and has dealt with well over 150,000 claims in that time. Whether it has done so effectively is probably neither here nor there when GPs look at it as a provider. The question is ‘am I covered?’.

So, a quick consideration of what we know. First the good news; there is no limit on coverage under the scheme and no excess so there will be no need for ‘top up’ coverage. It covers situations where the person against whom a claim is made has died, is bankrupt or insolvent, or where a practice has been wound up – provided that the claim fell within the scope of CNSGP at the time of the alleged negligence. The majority of GP staff are covered (including sessional GPs) for the majority of services, treatments and procedures that they perform on a day to day basis. The exceptions are as follows:

• Where an eligible person has made an admission of liability without Resolution’s agreement;
• Where court proceedings have not been referred to Resolution;
• Where a condition imposed by Resolution has not been complied with; or
• Where the eligible person has failed to assist Resolution in managing the claim.

None of these sounds ridiculous but the last two are a bit subjective. It seems unlikely that they would be used as grounds for excluding coverage, but GPs can expect to have various hoops to jump through as part of any claim. Follow the rules, say nothing and make sure your staff do the same would appear to be the default position. As regards staff and types of treatment exclusions, a PCN Clinical Director is not covered (but then again, this is not a role that should involve treatment of patients) but effectively all other staff are covered providing they are carrying out activities in connection with the delivery of primary medical services or ancillary health services under a GMS, PMS or APMS contract. As regards treatment and services, occupational health injections are excluded unless staff members are practice patients, as are travel vaccinations where the patient is required to pay and some reports (for example safeguarding reports). Obviously all private services are not covered.

It is a pretty good deal and will take some of the financial pressures off GPs. It is being paid for via a one-off sum that is part of the new contract calculation so there is no ‘free lunch’ but cashflow should improve as a result and this can be turned to other things. One obvious caveat is that the cover is not for public liabilities, buildings or other business liabilities. GPs will continue to need separate cover for all of these things. Nor does it cover representation in front of professional bodies (like the GMC). The scheme does tie GPs increasingly in to the NHS bureaucracy and some GPs may not like this but that is the price of what is pretty comprehensive cover. If asked to decide to take it or leave it, it would be an odd decision indeed not to say take it!

Welcome to your PCN

So the dust has settled and according to NHSE (who will be giving themselves a huge pat on the back) 99.5% of you have joined a PCN. By the way that means you have signed a legally binding document but let’s come back to that later. So you have done the hard bit and now you can sit back and relax and all the promised new funding (£4.5bn by the end of 2023/4) will flow in. Happy days.

Except…. Not quite the way its going to work. It sounds like a lot of money but given you are dealing with NHSE in its present frame of mind, there are strings attached. Quite big strings in fact. Ian Dodge, National Director of Strategy and Innovation has just released a paper entitled ‘Implementing the Long Term Plan in primary and community services’ and you should probably all have a read of it. It is 83 pages worth so you may well not have the time to do so but fear not as I have read it and here are some thoughts.

So let’s start with how the money flow works. I’m afraid it isn’t as simple as dividing the £4.5bn by the number of PCNs (which incidentally is quoted as 1259) and sending that amount on an annualised basis to you all. Rather it is all part of the creation of Integrated Care Systems and actually it does make sense to tie the extra money into a system-driven approach. Primary care will have more moving parts than just General Practice and GPs are probably not unhappy about that because they won’t want to do all the extra work that is being planned themselves. So going forward, the extra money will form part of the minimum spending requirement (a) at the level of every ICS in 2023/24, and (b) at the level of every region from 20/21. Supposedly this will avoid unrealistic backloading, whilst giving regions some flexibility in the three years between 2020/21 and 2022/23. Every region will operate the guarantee for April 2020 onwards. To meet its required share of the regional guarantee from April 2020, each CCG and STP/ICS will need to:

(i) fully honour 100% of the GP contract entitlements each year; plus
(ii) spend at least their agreed share of the remaining cash amount of the
guarantee each year.

This amount will include the baseline of pre-existing 2018/19 planned spending levels on primary care, community health and CHC services. All CCGs – even those with the lowest growth – have been funded in allocations to deliver their share of this guarantee.

So all this means that you are going to be tied into the system, like it or not. The payment would still appear to be in the hands of the CCGs as well but what latitude they will have to pay or not remains to be seen. However it looks as if NHSE (via the CCGs) is not ready to give up ‘control’ yet: ‘Some have suggested that PCNs might assume CCG statutory functions, such
as population need assessment, or can be the reincarnation of the GP multifund or Total Purchasing Pilots. This is neither our intention nor legally possible. The primary care network is not about commissioning. Instead, PCNs are about collaborative provision.‘ Note the bolded text (which is actually in the document). I’m afraid that you won’t get to decide how to spend the money therefore. However opportunity might still come knocking because a load of new services (especially the community services) may well be up for grabs and PCNs (or clusters of them) could bid for these. More of this in a later article about business opportunities.

NHSE has set some pretty lofty ambitions for itself on the back of the PCN ‘revolution’, namely:

(i) they will have stabilised the GP partnership model;
(ii) helped solve the capacity gap and improved skill-mix by growing the
wider workforce by over 20,000 wholly additional staff;
(iii) become a proven platform for further local NHS investment,
including in premises;
(iv) dissolved the divide between primary and community care services; and
(v) having done (i) to (iv) first, achieved clear quantified impact for
patients and the wider NHS.

So are you convinced? Hmmm…. Me neither. Loads more work to be done before NHSE can continue the pat on the back exercise and declare ‘mission accomplished’.