GPs condemn new specifications for primary care networksBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m258 (Published 27 January 2020) Cite this as: BMJ 2020;368:m258
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I have so many issues with the Primary Care Network Contract that arrived in General Practice last year that I am not really sure where to start. I suppose I could start with searching for the positive. Investment in primary care has to be welcomed and I believe in scale, collaboration and new types of staff, all being brought to bear on the needs of our patient populations. But when I look at this contract I can’t help but think “we asked for a horse, what’s this?” It reminds me of the late great Spike Milligan’s poem for children:
The self-made giraffe was mentioned in dispatches
For making himself
Out of sawdust, string and patches
Firstly, the timelines; why the rush? I am fairly experienced at building organisations, companies, collaborations and teams. The short timelines do not support robust development of relationships or plans for service development or the sharing of staff resources. It adds to the panic-buying of the new forms of clinician, for example.
And what is a PCN? A lengthy prescribed legal document links practices together into a, what? There are well established robust legal structures that exist already. What has been created here? Will it stand the test of legal challenge, failure, fraud, clinical negligence? And why the restrictions on size? For example the funding for staff, even the new bursaries, gets reduced for smaller PCNs below 50k patients but not above until over 100k patients. Why ? It as if there is a desire for GPs to work together, but not too well together because they might actually have some impact? Perhaps somebody looked at the NAPCs primary care home system and mistook positive cultural shift for dogma. In both regions that I work the effect of this new system was to cause disruption to existing and functioning sizeable and incorporated collaborations. One lost members but holds the PCN contract. Another still exists holding an extended hours contract – remember that last year – but has divided into two smaller PCNs as well. The work and effort that has been lost and continues to be lost to make some sense of the rules, restrictions and consequent implications of the PCN contract nationally must amount to tens of thousands of in senior clinical and managerial hours.
Next, the “new forms" of staff. For many practices many of these staff and even social prescribing are not new. But they don’t count. You must start again; with certain exceptions where special rules written in unicorn tears apply. And you can only have one of each or a percentage at a reimbursement rate that is now irrelevant because the timelines, added to the fact that the staff investment money cannot be carried over or flexed into staff types that your patients may actually need, or even increased existing staff costs, means that market forces are driving up the costs of the staff that everyone is suddenly searching for. I mean, the intent is great. Someone heard that doctors are scarcer than actual unicorn tears but that innovative deployment of other clinicians was making a difference in various parts of the Country. But why the restrictions and timelines? The whole process smacks of a 1970’s Eastern European Communist five year plan for tractors. Tractors must be produced at this rate regardless of the fact that they cost twice as much as envisaged and there is no one who can drive them because all the tractor drivers are being pulled away to meetings about tractor production.
Lastly, the funding. For the CCGs and practices in the middle of all this, this is not really new money. £1.50 per head was largely already being deployed on other things. This funding, in particular in one CCG we are in, is now lost to those things. Moreover it isn’t enough to support the development of the complex collaborative organisations, to run them and backfill the senior staff needed to run them. Certainly not at the smaller end of the PCN scale. Desperate for investment, once again, I watch primary care fighting over the small change whilst trying to deliver big change. Many will probably achieve it, and should be rightly applauded for doing so because it will almost be in spite of the contract rather than because of it.
You may appropriately ask what my suggested alternative is? Simple, free the intentions from the self-generated restrictions. Support data driven, local, manpower and service plans to be developed that match patient needs, practice needs and the local market and fund them appropriately and expect and allow regional differences to address inequalities. Support the established good and help those that have nothing already working to develop. Allow variation and build trust. Use policy and guidance not dogma. We need a workhorse, not Spike's giraffe.
Competing interests: No competing interests