PCNs and GP Federations – what are their roles within the new neighbourhoods?
Day three of our weeklong insights on the NHS 10 Year Plan sees the primary care team delve into the role of PCNs and GP Federations within the new neighbourhoods.
Do Primary Care Networks (PCNs) have a future?
The simple answer to this question is ‘yes’. For those practices who do not wish to merge to form Single Neighbourhood Providers there remains an essential role of delivering services across the neighbourhood and ensuring collaboration between the practices. PCNs will be the method through which this is achieved.
PCNs will become more important for those areas as the contracting of enhanced services and new opportunities such as outpatient services are likely to be required at a neighbourhood level. It will therefore be for the PCN to determine how this is achieved within their area.
This will be on a case-by-case basis but it could be through delegation to the member practices, sub-contracting to an incorporated vehicle representing the PCN, or sub-contracting to a federation or similar alternative provider.
There are however some risks which will need to be addressed. The most important one is the scale of the PCN. These have always been targeted at 30,000 to 50,000. However, they do vary with many being outside of these parameters. If the government insists on the 50,000 neighbourhood size then those PCNs who have been working at less than this may be forced to realign at the new working level.
In 2019 when PCNs were first introduced there were concerns that they broke down much of the hard work in many areas where existing localities had been defined. There is a risk that this could happen again. How this will be implemented will determine the level of disruption it may cause.
A second issue could be the alignment with other service providers who are likely to become more influential under this model. In most areas this is unlikely to cause too many concerns as much of this alignment work has been completed in recent years. However, areas such as London have already indicated that some PCNs may be required to restructure. In their recent paper entitled ‘A neighbourhood health service for London’ (NHS England — London » A neighbourhood health service for London) they stated:
‘Where local statutory boundaries, including those of current PCNs, align with such natural communities, the boundaries may be co-terminus. Where boundaries do not align, re-alignment to these footprints or development of local arrangements capable of operating efficiently and effectively across them will be required’
Dr Claire Fuller (Primary Care Medical Director for NHS England) has further advised that neighbourhoods need to be ‘geographically sensible’ and stated that:
‘If you’re a “doughnut” PCN – with a gap in the middle – we need to think for a neighbourhood how we get better geographical alignment.’
(NHS won’t ‘throw money’ at neighbourhood health sites, officials warn | GPonline)
PCNs are therefore an essential part of the Plan even if they are not frequently referred to within it. Practices should ensure that they continue to develop them and continue to work collaboratively with more integrated working.
However, if they are smaller than 50,000 and/or if they know that their boundaries are likely to be a concern for the ICBs, they should consider discussing terms with their local PCNs and ascertaining whether now is the time to undertake a PCN merge or restructure. This will be a time consuming process and dealing with PCN changes can be complicated especially given the integrated nature of the funding and services. It should therefore be carefully planned and managed. PCNs should avoid delaying this level of discussion as it may take 12 to 18 months to complete this type of restructure.
For those PCNs who feel that they are in an advance position and meet the size criteria they will need to consider whether their members have any interest in consolidating and becoming a Single Neighbourhood Provider. The Plan states that GPs will be ‘encouraged’ to work at this scale so it will be worth considering for some.
Most PCNs will however continue as they are and should ensure that they have the appropriate governance and structures in place to respond to the changes the Plan will bring about.
Will federations have a bigger role to play and if so how large should a federation be?
There is only one reference to GP federations in the Plan but it is a highly important one. They have been recognised as the entities which are currently providing roles that are similar to those which will be allocated to Multi Neighbourhood Providers in some areas. They are therefore recognised as the logical choice to provide this role in other areas.
The alternative provider of Multi Neighbourhood Providers would be either NHS Trusts or potentially other commercial providers. Federations must therefore be ready to positively respond to this role knowing that they may be competing with NHS Trusts.
They provide the opportunity for GPs to take a degree of control over a large scale of the population and to enter into the new NHS with a voice on par with the local NHS Trusts and social services.
Those which succeed in making this transition will be required to undertake the following functions as a Multi Neighbourhood Provider:
- Provide a range of administrative and support services
This includes:
- Developing a shared back-office function
- Overseeing digital transformation
- Developing estates strategy
- Providing data analytics and quality implement functions
Many of these roles are being decommissioned at the ICB level as detailed in the Model ICB Blueprint (The Model Integrated Care Board Blueprint – key insights – Hempsons) and consequently there should be existing workforces and budgets which will need to transfer in the very near future. If this does not happen it is unclear how this work will be funded by the NHS.
It is important to note that the Model ICB Blueprint included other services which are not include in the Plan. Services such as medicines optimisation, Infection Prevent and Control support and safeguarding could also be relocated into these providers. This would give the Multi Neighbourhood Providers a role in scrutinising compliance and supporting practices. A key question would therefore be where would practices prefer this to sit, in a GP federation or in another entity such as a Foundation Trust?
Federations may have some of this expertise in house but if not, they should consider where it can be sourced from to help prepare for these functions. It should be noted that NHS Trusts often have teams in these areas already so they may be able to offer a strong business case for taking on this function.
There is no reason in principle why a federation and a Trust could not develop a working partnership to jointly provide these functions.
There is however a significant risk to this work. It is not the provision of health care services and consequently it is not exempt from VAT once these services are provided to any other provider such as the practices. This creates a significant new strain on the budget if it is not structured and addressed correctly.
This risk shall be highlighted to the government and they may propose changes to ensure that this becomes or remains VAT exempt. However, if this does not occur federations will need to consider whether they can deliver the services using a Cost Sharing Group or look to provide them in a cost effective manner.
Whilst this is a potentially great opportunity there is a significant commercial risk which must be addressed before any contract is agreed for the provision of these services.
- Providing coaching and support to practices, with the option of taking them over if necessary
This is an area of expertise and resources which federations should be in a strong position to provide. They are normally owned and run by GP partners and practice managers who have the knowledge to support struggling practices.
The exact function and nature of this support needs to be properly defined, as does any funding arrangement to be applied to it.
Whilst federations do have a track record of taking on practices this has historically had a varying degree of success. Taking over struggling practices is by its nature very difficult and requires significant additional support and resources. This is not likely to be a model which would work well for providing ad hoc and limited patient services.
However, if they can be used to reach a critical mass i.e. to provide services across a neighbourhood this is likely to have a major positive impact on the practices involved and the federation.
- Representing general practice
This level of scale provides a single voice for general practice when engaging with NHS Trusts, social services and commissioners. This should be developed in conjunction with the local LMC and it can make representation on subjects which are outside the scope of the LMC’s role.
It is essential that it maintains the ability to say that it is representative and the structure of the federation should be considered to achieve this.
The relationships with practices, PCNs and in the future the neighbourhood providers will ultimately determine the success of the federations in this new function. Appropriate committee and communication structures must be developed to ensure that this can be maximised for the benefit of general practice.
For those federations aiming to work at the scale of 250,000 or more patients the Plan represents a unique opportunity to maximise the benefits to general practice within the new structure.
It should be noted that there is likely to be a continuing function for smaller federations, especially those who operate as high quality service providers on behalf of their member practices. They will need to define their role in the larger provider landscape but they may remain service or function specific federations. For example, they may provide home visiting services for their member practices or front-end GP support in urgent care. There is no reasons for them to stop providing these services if they are supported by the wider commissioning and provider group.
They will have to ensure that they engage and work as part of the structure to avoid losing opportunities but as many of them have strong track records of providing quality services they should be confident of their continued functions.