Five action points for a PCN to prepare for the future
Reviewing things now will help ensure Primary Care Networks (PCNs) have the framework and flexibility to evolve and develop to meet the demands of 2024, advise lawyers Justin Cumberlege and Robert McCartney.
PCNs have become the conduit for a significant proportion of funding into primary care and the management of this has resulted in a new way of working for many GPs.
This includes shared clinical teams, large numbers of new staff and the potential for securing additional revenue streams. However, the current five-year contract framework plan for PCNs ends on 31 March 2024, and potentially the loss of funding.
There remains no official statement on what will replace the current GP contract in April 2024. The current contract included the most significant changes to the way primary care has worked since 2004.
At its heart was a focus on developing and promoting a new way of collaborative working across practices in the form of PCNs.
However, practices through their PCNs may be facing significant liabilities and be forced to restructure how they work if the new contract does not offer the assurances required.
Some have taken precautionary measures, sometimes in conjunction with their federations, who have helped deliver PCN services, or by forming PCN service companies.
The delivery plan for recovering access to primary care published by NHS England in May 2023 confirmed that working at scale in general practice, improved integration, and increased focus on communities and patient designed care, will remain at the heart of future NHS England plans.
But it did not provide certainty on PCNs specifically and stated the following:
‘The 2024-25 contract provides an opportunity, after the 2019 five-year framework ends and the PCN DES was introduced, to reflect on successes and lessons learned.
‘We will explore alternative approaches that can work alongside the partnership model and explore additional opportunities to better align clinical and financial responsibilities in primary care, enabling primary care teams to shape NHS services in their area and reinvest savings in frontline services.’
While this review is welcome there is little sign that it has commenced, and the clock is ticking for the negotiation, publication and implementation of a new contract in April 2024.
This is a risk but it is easy to forget that, regardless of the outcome of this review, primary care is in a stronger position to adopt future changes than it was in 2019.
There were then exceptions such as those areas supported by the National Association of Primary Care’s Primary Care Home concept. But across the country there was little incentive to work collaboratively or to explore new methods of working at scale.
This is no longer the situation, and PCNs provide the basis of how each area will adapt to future changes.
Here are five areas to review which will help ensure PCNs have the framework and flexibility to evolve and develop to meet the demands in 2024.
PCNs have multiple complex relationships and it is essential for these to be properly formalised. A suitable contract will give certainty and provide the mechanisms needed to develop the relationship, or possibly terminate it as more clarity about the future is revealed.
The first step is to assess which relationships may benefit from having contracts. These are three key categories of relationship:
A – Contractual relationships between PCN members (not least the network agreement itself)
B – Sub-contracted services with third party providers
C – Contracts with suppliers
Are agreements in place for each category? If not, each PCN should consider entering contracts to establish certainty for the relationship for this year, and a template in the future.
In agreeing the terms of the contract the following questions should be asked by each PCN:
- Are there clearly defined service delivery requirements and how are these monitored?
- What mechanisms exist to ensure delivery is to the appropriate standards?
- Is the contract based on a published specification, and if so, is the whole of that specification applicable, or only part
- How is that part defined, and does it fit neatly with the provision of the other part?
- Are there key performance indicators and reporting requirements that match NHS requirements?
- How do the finances work and how is this tracked?
- Can you be assured of, and measure, the quality of the service you are receiving?
- Does the timeframe for the contract match your requirements for the service: how can it be terminated early and can it be extended?
- How do you manage issues if problems arise and, in more serious matters, how are disputes managed?
- With the network’s agreement – does it reflect the way you are conducting the network at present? If not, does the agreement need to be changed to reflect it, or do you need to change the governance of the network (as well as corporate, perhaps also the financial and clinical governance)?
These simple questions will help to identify areas where improvements can be made and will allow the PCN to understand how these relationships work prior to any changes which may be needed in early 2024.
The NHS England Update to the GP Contract agreement 2021-2023/24, clause 1.20, made the following commitment:
‘…we can confirm that the level of reimbursement already drawn down to support new staff employed by a PCN will now be guaranteed during this GP contract period…and these staff will be treated as part of the core general practice cost base beyond 2023-24 when we consider future GP contract funding, like the practice global sum…’.
This provides some certainty that funding will be made available to support current staffing. There are questions about what will happen to any underspend and, if there is an overspend, using money from other PCNs. There are also questions about the meaning of ‘core general practice cost base’ which need clarification.
It does not necessarily mean that the core general practice will employ the staff. There is a credible argument for contracts to be awarded to the ‘best provider’ in the area, and if the PCN is dysfunctional, then it may mean another contractor being awarded the contract.
However, as a principle, PCNs can take the following steps with some degree of confidence:
A – Ensure maximum use of the funding to avoid discussions about losing potential revenue in the future;
B – Clarify employment terms and ensure consistency between the different employees, this is particularly important if the PCN is operating on a multiple-employer model; and
C – It is likely that the uncertainty surrounding PCNs will create uncertainty in the team so undertake engagement events to give the assurances and regular updates to alleviate these concerns.
Include a ‘worst case scenario’ of being transferred to another employer under the Transfer of Undertakings Protection of Employment (TUPE) regulations.
3. Resolving disputes
Disputes within PCNs are becoming more frequent. These will derail your plans and the future of the PCN and collaborative working initiatives. This year may be the final chance to bring these issues to a close and to work on finding solutions.
Knowing that you have resolved, or at least have improved relations, will give the PCN a far better chance of managing the changes in 2024, and potentially, holding onto contracts. Facing periods of uncertainty is easier when you have a good foundation.
Regardless of the reason for the dispute PCNs should consider taking the following steps:
A – Properly define the problems: this can be achieved through improving engagement and communications and tools such as a root cause analysis may help to bring matters to light which are deeper than those currently under dispute;
B – Seek informal support: LMCs are particularly useful and although they cannot take a side or participate in a formal dispute resolution process, they can facilitate discussions and help to find resolution;
C – Use the mechanisms available in your network agreement and if necessary, engage experts to help, including lawyers, mediators and arbitrators;
D – Only in extreme circumstances consider restructuring your PCN. This will include working closely with your ICB and local PCNs who may be affected.
Underpinning many disputes is the quality of the governance within your PCN.
Governance can be misconstrued as over-complicated processes and creating documents for the sake of it. In practice it should simply be a system by which everyone involved in the PCN can feel assured that it is being managed appropriately.
At the most basic level it should show how, where, when and why decisions were made. This is a simple way of showing people had the opportunity to participate and that the decisions reached were reasonable based on the information available.
Many potential disputes have been resolved by a clinical director providing the discontented party with evidence that they were asked their view and had the chance to participate but failed to do so.
As these systems develop people have greater trust in the individuals and the relationships grow stronger. This will underpin success when the new contract is released.
Transparency is fundamental, particularly when it comes to the receipt and the payment of funds. All PCNs should now have a separate bank account into which the PCN funding is paid, albeit that it is controlled by the nominated practice.
The financial position of the PCN should be clear. Not knowing how monies are spent and not having a clear understanding of the financial consequences of decisions such as extra recruitment or using a third-party supplier leads to disputes in many cases and may lead to genuine errors placing the PCN at risk of losing money.
Robust financial governance, such as developing a budget and a system to report against the budget on a regular basis will help resolve this issue. Limitations on what can be spent and by whom will provide some assurance to the members.
If a PCN is facing financial difficulty early engagement with its specialist accountants is essential to work through these issues and to understand the risks. The revenue of PCNs has
reduced following COVID-19 and it is important this has been accounted for in future expenditure plans. Historical issues are important to resolve and PCNs need to ensure the current finances and future expenditure are treated separately. This will be the strong building blocks for the future. Past issues can then be resolved knowing that they do not impact on the future.
The future of PCNs is uncertain but looking at each of these areas will provide PCN leaders with the infrastructure, relationships and assurance required to face this uncertainty in a strong position.
Any announcement in advance of April 2024 should be met with confidence, by having an understanding that the PCN can manage this change and retaining its contractual and financial position.
First published in AISMA’s Summer 2023 edition.