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.