Here’s how to get your Primary Care Network off to a healthy start
Progress towards the deadline for Primary Care Networks in England (PCNs) to finalise their mandatory network agreement has not been as smooth as might have been hoped.
As I write this, some PCNs have not yet received confirmation that the composition of their PCN is approved – and some practices have still not found a PCN to join. Hopefully, by the time this article is published, most of these issues will have been resolved and PCNs will have started delivering the NHS England Network Contract Directed Enhanced Service (Network DES).
But of course that is far from the end of the story. While the focus has been very much on the formation of PCNs in time for the commencement of the Network DES, PCNs are now moving into the delivery and development phases, where the work really begins in earnest. Some PCNs will already have addressed many of these issues in the course of finalising their Network Agreement, whereas others might not yet have had the opportunity to do so and might need to revisit them to ensure they are robust enough to enable the PCN to deal with the challenges ahead. Although this article focuses specifically on PCNs formed under the Network DES, many of these issues will be applicable to networks in other parts of the UK.
The leadership role of the PCN’s clinical director will be central to its success. However, the time and funding available for the clinical directors’ roles will be limited and they will need to work closely with practice representatives. Many PCNs will already have formed some kind of board or council of representatives. It is essential that the clinical director and board’s respective roles, duties and how they work together is defined and agreed. PCNs will also need to think about the appointment process for renewing or replacing the existing clinical director if they have been appointed for a fixed period or if they resign. It is quite possible that the clinical director’s job description and person specification may evolve as the PCN develops, and this will have to be kept under review.
Membership engagement and involvement
A key focus for PCNs in the early stages will be ensuring that member practices are engaged in discussions and involved in PCN activities. This will be particularly important where practices have been allocated to PCNs rather than membership having evolved through the choice of the member practices. It is important that the PCN’s communication and decision-making processes allow for the views of all the member practices to be heard. The PCN will need to consider how frequently meeting of the whole PCN membership should be held and what decisions are to be reserved for decision by the general membership rather than being delegated to the board or clinical director.
Practices that did not meet the deadline for signing up to the Network DES or have not yet joined a PCN could still do so with commissioner approval and the agreement of other practices in the PCN. They will need to either join an existing PCN or even form a new PCN (if there are other practices in a similar position within the same locality) and sign up to an existing or new network agreement.
The network DES requires that all payments are made to a single nominated practice on behalf of the PCN. It is important that the money is held in a separate bank account and subject to proper controls. We are aware that at least two UK banks are enabling special arrangements for PCN accounts so that partners from other practices can be added to the bank mandate. The PCN should have clear procedures for authorising payments out of the PCN account and systems to monitor the account and ensure that PCN funds are being used correctly.
Extended access delivery
The PCN is required to commence delivery of extended access services under the Network DES from 1 July. PCNs will need to have a clear plan in place for which practices will be delivering what extended access services and on what terms, or whether there will be a single lead practice with overall responsibility for service delivery.
Alternatively, delivery might be subcontracted to a third party, such as the local GP federation. If so, an agreement must be put in place between the PCN and the federation which complies with the GMS/PMS subcontracting requirements. The network agreement should set out arrangements for service delivery, or mechanisms for agreeing them, including arrangements for allocating payment for the services and any management costs. If these matters are not dealt with adequately in the network agreement, the board will need to ensure that appropriate arrangements are agreed as soon as possible to minimise the risk of disputes.
PCNs will need to consider if they wish to recruit clinical pharmacists and social prescribers which are funded in whole or in part by the Network DES, and any other roles that the practices wish to fund themselves. Consideration must be given to the job descriptions and person specifications for the roles and who will employ them on behalf of the PCN. Will they be jointly employed by all the practices, employed by a lead practice on behalf of a PCN, or will a third party (such as the federation) employ them? It is important to take specialist tax and accounting advice on the different options as well as legal advice because there are complex considerations. Thought should be given to whether the employer can provide access to the NHS Pension Scheme for the PCN workforce.
Reporting and monitoring
PCNs will need to comply with the reporting and monitoring requirements in the Network DES. Systems should be put in place (if not already) to see that practices and any subcontractors comply with these to ensure Network DES requirements are satisfied.
Underperformance, breach, risk and liability sharing
PCNs will need to consider how they will deal with a situation where a practice underperforms against agreed Network DES targets, fails to comply with other issues, such as reporting requirements, or breaches the network agreement. There might be both a carrot and stick approach in these situations. The PCN leadership may seek to support the practice to improve but ultimately the other practices are unlikely to be willing to suffer financial loss resulting from another practice’s default. So the network agreement should have provisions to enable the PCN to recover losses from a guilty practice. Ultimately, the PCN needs to be able to expel a practice that is in serious or persistent breach of the network agreement and there should be provisions governing how and in what circumstances this can happen. The network agreement also needs to address how losses and liabilities generally will be shared where these are not the responsibility of an individual practice. Will they be shared equally or according to patient list size or in some other proportions?
Engagement with patients and the wider system
NHS England has made it clear that PCNs are regarded as a building block towards greater integration between primary care and the wider healthcare system. A key challenge for the PCN leadership will be to represent primary care in emerging integrated care systems and to build relationships with other health and social care providers, commissioners and other PCNs. The Network DES also foresees a role for PCNs in engaging with patients in developing new services and pathways.
Many PCNs have found the process of getting formed in time for the commencement of the Network DES very rushed. They have often not had adequate opportunity to consider the structure of their PCN or their governance systems and many have not included enough detail in their network agreement. As PCNs are fledgling organisations, their structures and processes are likely to evolve over time. Some PCNs will need to do more work on their network agreements in the early stages to ensure they are robust enough to deal effectively with the various issues and challenges ahead. As practices work more closely together within PCNs this might result in more fundamental organisational changes such as practice mergers or formation of super-partnerships which go beyond the scope of the Network DES activities.
Preparations for the 2020-21 Network DES… and beyond
New services will be added to the Network DES from April 2020. Once further details are available, PCNs will need to ensure arrangements are made to deliver them. The network agreement might need to be updated accordingly, although a well drafted one should largely be future-proof and make it unnecessary to rewrite each time.
This article first appeared in the Summer 2019 issue of AISMA Doctor Newsline, the newsletter of the Association of Independent Specialist Medical Accountants.