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’.

NHS England has released the mandatory Network Agreement which all PCNs will have to sign. It consists of two documents, the agreement and the schedules. Given the importance of this document (bear in mind that in future, payments to GPs will increasingly be made to PCNs and less to individual practices), it is a bit thin. Terribly thin in fact. Rather than pick it apart, let us instead consider what it actually says and what is left in the hands of GPs to sort out for themselves.

The Agreement

This is the document that all members of the PCN must sign. It is categorically stated as ‘legally binding’ and so will govern the future relationship of the practices which make up the PCN. Given various sums under the new network contract will flow to the PCN directly (and not individual practices) it will govern these money flows. There are 106 clauses and you would be forgiven for thinking that this is where the ‘meat’ is. These cover general obligations and patient involvement, financial arrangements, workforce, information sharing and confidentiality, conflicts of interest, conflicts of interest, meeting format (governance generally), joining and leaving the PCN, duration and variation, termination, dispute resolution and ‘events outside our control’.
Except they don’t. The clauses in the agreement all refer to the schedules for greater detail. The schedules document is, however, a series of blanks, leaving PCN members to fill in as necessary. This is not particularly helpful and leaves GPs to sort out a host of vital issues themselves. The top 5 are:

Financial arrangements
There are so many issues under this heading. If one practice in the PCN is designated to receive PCN payments, how will it pay what is owing to other practices? When? On what basis (i.e. what happens if another practice does not provide the PCN services required)? How will be accounted for? What happens when there are other organisations other than practices involved? What about possible insolvency of a practice; how will this impact the PCN? What about intellectual property rights of individual practices/partnerships? How will these be protected? Can individual partners of member practices be sued for the liabilities of the PCN? No detail. Not good.

Workforce
Given the fact that money is being made available for additional roles (but not at 100% reimbursement), who will employ them? If the practice that is the designated fund-holder does, is it aware of the implications from an HR perspective? If another organisation employs them (i.e. a new company), there will likely be VAT issues. This has the potential to create horrendous problems.

Governance
How will the PCN decide on pressing issues? It will need to have some a ‘board’ of some kind and who will be on it? What will the role of Clinical Director be? Will representatives of the ‘board’ have authority to bind individual partnerships? What is the legal status of decisions made? What about liability issues? How will a PCN vary the agreement if it needs to? Many, many open questions.

Joining and leaving the PCN
This is probably the most glaring ‘omission’ (given the schedule simply says ‘fill in the blanks’). How do practices leave and are they even able to do so? Can a PCN expel a member practice? If so, how? If a PCN expels a practice, what becomes of the patient list? How will they still receive PCN services?

Dispute resolution
What happens if things go wrong? What is the legal status of member practices within the PCN? Who will act as arbiter in the event of a dispute?

Timing is obviously an issue. The ‘initial’ network agreement must presumably be signed by all member practices by June 30th.  The current version does at least say that the agreement can be varied from time to time, but this first draft is so devoid of detail that PCN members really must get specialist advice before signing anything. Lawyers are expensive and it is only the national firms that have the breadth of experience to give a detailed view. They are very expensive. GP’s need specialist advice on this vital issue. And fast!

It is fast becoming clear that the Network Agreement that all PCNs must have in place and which must be signed by all practices involved is not simply a ‘rubber stamp’ exercise and could have serious implications for the future function of a PCN.Justin Cumberlege, a partner at Hempsons which is a national firm with significant experience in General Practice, recently told GP Online that network agreements are legally binding contracts and skimping over the detail could lead to misunderstandings, and at worst disputes and claims in the future. He encouraged GP partners to reduce the risk of individual liability by ensuring ‘all partners’ involved in a network are signed up to a contract that ‘binds the partnership’. This is no minor matter. Timing is tight; network agreements must be in place (with other paperwork) for a 30th June deadline and this does not leave a great amount of time to digest and agree something which could affect how a PCN operates.

The significance is that PCNs are the only way to ensure access to the proposed DES and also the new network services, which are likely to account for the bulk of the new monies promised under the new GP contract framework. There are also very significant potential issues surrounding employment law and VAT depending on the structure used to manage the PCN.

GPs need to be very aware of the issues that surround this essential step and should take appropriate advice. Tanza Partners is able to give a full range of such advice and can draw up and execute an an appropriate network agreement that is tailor-made for any group of practices. Please get in touch to find out more.

John Tacchi
07780 956850
john.tacchi@tanza.co.uk

Good news or bad?

The new GP Contract Framework has been released and this will form the basis of a new contract for the next five years for GP services. It has been agreed by NHSE and the BMA and will apply for the contract year 2019/20.

The new contract has the following goals:

1. Address workload issues resulting from workforce shortfall.
2. Bring a permanent solution to indemnity costs and coverage.
3. Improve the Quality and Outcomes Framework (QOF).
4. Introduce automatic entitlement to a new Primary Care Network Contract.
5. Help join-up urgent care services.
6. Enable practices and patients to benefit from digital technologies.
7. Deliver new services to achieve NHS Long Term Plan commitments.
8. Give five-year funding clarity and certainty for practices.
9. Test future contract changes prior to introduction.

Significant funding is promised within the terms of the framework to achieve the goals and this will create a lot of interest at practice level. The clear mandate to create Primary Care Networks (‘PCN’) will be a significant change for General Practice and could be truly transformative. However not all of the details are clear and the process must be completed by May 2019. This will not be an easy as the level of awareness in practices will vary dramatically and the diktat is clear – the funding only flows if all practices in a PCN are members.

The introduction of Primary Care Networks is a clear attempt to begin the process of ensuring General Practice works ‘at scale’ and a new Network Contract DES is being introduce to provide ‘impetus’. As a DES, it will be an extension of the core GP contract, not a separate contract. The commissioner of the Network Contract DES will likely be the CCG in nearly all instances.

Timing is tight – GPC England and NHS England are committed to 100% geographical coverage of the Network Contract DES by Monday 1 July 2019 as a ‘go live’ date.

To be eligible for the Network Contract DES, a Primary Care Network needs to submit a completed registration form to its CCG by no later than 15 May 2019, and have all member practices signed-up to the DES. It asks for six factual pieces of information:

1. the names and the ODS codes of the member practices;
2. the Network list size, i.e. the sum of its member practices’ registered lists as of 1 January 2019;
3. a map clearly marking the agreed Network area;
4. the initial Network Agreement signed by all member practices;
5. the single practice or provider that will receive funding on behalf of the PCN; and
6. the named accountable Clinical Director.

Clearly there are a number of steps which many practices will not be prepared for; the requirement of a ‘Network Agreement’ is important and, as yet, NHSE has not produced a draft.

Formation is also an important consideration. NHSE is clear that this is not an invitation to GPs to ‘team up with their mates’. List size is expressed as ‘at least’ 30,000 people (although it is not clear if this is registered patients) and a PCN should not extend over 50,000. The PCN must make geographic sense to:

(a) its constituent practices;

(b) to other community-based providers, who configure their teams accordingly; and

(c) to its local community.

Interestingly the patients of a practice that does not want to join a PCN must be included in a PCN and all payments will still flow to the PCN lead.

Funding in year 1 will consist of:

• 0.25 FTE per 50,000 of population for the Clinical Director;
• £1.50 per registered patient. This payment is a recurrent extension of the existing £1.50 per head support scheme, which was set out in the December 2018 NHS planning guidance;
• NHSE will establish a new development programme for PCNs; and
• CCGs can provide support in kind.