PCNs, STPs, ICSs and all that

1. PCNs,STPs,ICSs and all that Dispensing GP Cullompton Devon Board Member Dispensing Doctors'Association

2. Today • Review of current NHS policy and the Long Term Plan • CCGs,STPs, ICSs and, potentially, ICPs • The changes to the GP contract • What do PCNs and contract changes mean for dispensing doctors? • What happens to PCNs in future? • Does the workforce for PCNs exist? • Potential future political and NHS changes

3. This presentation isinherentlycautious You will have had plenty of hard-sell on the benefits of PCNs I won’t repeat all of that I will strive to set a balance

4. The NHS Long Term Plan • Published January 2019 • Takes over from The Five Year Forward View published October 2014 • Was (and still is) largelyovershadowed by Brexit • Sets the context for the new GP contract changes • Heralds transition from CCGs and Sustainability and TransformationPartnerships (STP) to IntegratedCare Systems (ICS) • Does not include a workforce plan

5. Some reflections on the previous 5YFV • What happened to multi-specialty community providers (MCPs)? • Are these now rebadged as PCNs? • What happened to primary and acute care systems (PACs)? • Are these now rebadged as ICSs? • Much of what has planned has not happened • Pledges and plans often don’t deliver, i.e. +5000 wte. extra GPs by 2020 so far c.700 less

6. The NHS Long Term Plan mainthemes • “We will boost out-of-hospital care and finally dissolve the historic divide between primary and community health services” • The NHS will reduce the pressure on emergency hospital services • People will get more control over their own health and more personalised care when they need it • Digitally enhanced primary and out-patient care will go mainstream across the NHS • Local NHS organisations will increasingly focus on population health -moving to ICS everywhere.

7. CCGs and STPs to ICS • CCGs established under legislation designed for competition • That legislation still exists but focus now on collaboration • So fiscal/policy mismatch, government has no majority to rectify this so confusing approach • Long Term Plan signals creation of ICS (of CCGs and local providers of health and social care) • Signals future of one CCG per ICS: c. 40 ICS currently 191 CCGs • So mergers -watch the PMS funding baseline!

8. MPIG fair shares for GMS is a nationalfair shares program PMS premium review -balances out within CCGs but not a national fair shares process Different CCGs have differing PMS baselines based on historical PMS take up and investment So if your CCG plans to merge check what the effect on PMS baseline will be Make sure your baseline is protected -you should be consulted on any merger

9. STPs and ICSs • STP not legal entities but collaborations of local commissioners and providers to aid collaboration • With NHSE delegating primary care commissioning to CCGs this moves primary care budgets into local system budgets -ICSs • ICSs take over from STPs and target is for all England to be covered by these by 2021 • ICSs will be charged with delivering NHS Long Term Plan goals within a fixed budget for their area • Designed to promote joint planning and working and prevent one provider seeking to profit at expense of another or the commissioner • Intent to enshrine all this in legislation (when someone has a majority!)

10. Watch out for Integrated Care Providers (ICPS) These are contracts to a provider for a range of services e.g. GP services, community services, acute services These are like accountable care organisations in the USA Dispensing rights would fall under such a contract

11. Evidence For Vanguards

13. PrimaryCare Networks (PCN) • PCNs designed on this evidence to be the basis of investment for £4.5 billion extra resource to produce integrated multidisciplinary teams • Leading to creation of fully integrated community based healthcare • Based on populations of 30,000-50,000 patients (but already exceptions to that rule) • CCGs encouraged to apply local enhanced services through PCNs in future,“will normally be added to the network contract” • Founded as “an extension to GPs current contract”

14. PCNs • However these are not compulsory for GP practices to join • PCN DES was negotiated as a DES to avoid need for competitive tender • However compulsory for all patients to be covered by a PCN – CCG's role to ensure this. • If a practice does not take up the DES - the DES for those patients will be held by a PCN responsible for providing such services. • For this year -means extended hours only but in future years…..

15. PCNs 2019 • Had tobe established by 01/07/2019 • Must cover a defined area and defined number of named practices • Must identify a clinical director • Must provide extended hours to all patients (but there is an opt out here )-but leaves CCG discretion to vary the monies paid for extended hours and the PCN DES • Extended hours do not need to be provided by all practices , but be available to all patents in PCN. • Note extended hours DES now worth less than before (£1.45 v £1.90) -based on previous spend not budget

16. PCN incentives • PCN DES - £1.76 per pt per annum per practice (in 2019 for signing up ) • £0.514p per pt for clinical director 2019 (9 months) • £1.50 per pt for core PCN contract (to support the functioning of the PCN) -comes from CCG allocations • £1.45 p per patient for extended hours per annum (£1.1 in 2019) • 100% reimbursement of social prescriber up to £34,113 (9/12) • 70% reimbursement clinical pharmacist up to £37,810 (9/12)

17. PCN requirements 2019-2020 • Sign folks up • Appoint a clinical director • Have in place data sharing agreements by 30/06/19 (note the national ones promised were not published until July) • Nominate a lead practice for payment • Make extended hours available to your PCN population (but note opt out) • Use various codes when available for recording activity

18. Sounds Too Good To Be True? It probably is!

19. Complications for dispensingdoctors • Dispensing doctors are VAT registered -other practices usually are not • Thus great care needed if dispensing doctors hold monies for the network and when employing staff • Health care provision is VAT exempt but “services” are not -be careful how contracts are written and seek expert legal and accountancy advice • Social prescribing potentially not a “health service” • If extended hours provided by other practice staff without a contract with your practice, be careful when dispensing scripts (? get GP to check) • Dispensing rights are lost if the PCN becomes a limited company for providing core GMS or PMS

20. But PCN DES getsharder in future • From 01/04/2020 it will be compulsory for PCNs to collaborate with other non GP providers (exactly what this means unclear) • Seven new specifications to be delivered: • From 01/04/2020 - structured medication reviews • Anticipatory care (care planning etc) • Enhanced health in care homes (weekly visit stated) • Personalised care and personal budgets • Early cancer diagnosis (through QOF quality module)

21. PCN DES getsharder • From 01/04/2021 • CVD prevention and diagnosis • Tackling neighbourhood inequalities • And from 2020 a PCN dashboard, against which success will be judged based on various metrics • Reimbursement figures for 2020 not published yet but move to weighted capitation (small PCNs could get less) • Its <6months till employment date for new roles -we need the info now • And the Impact and Investment Fund -cash bonuses for those considered to be doing well

22. Impact and Investment Fund • All very uncertain at present • No details on indicators to be used, but stated will cover: • Emergency hospital admissions • Prescribing • Out Patients • A&E attendances • Hospital discharges

23. Impact and Investment Fund • Will be negotiated with GPC • Access to fund will include national as well as local elements • There will be rules on how it can be spent • PCNs must agree with their ICS how it should be spent! • Key question -is this a legal entitlement or discretionary at ICS level? • If latter, if ICS is broke (it probably will be) payment can be withheld

24. 2021 and Access By April 2021 we intend that the funding for the existing Extended Hours Access DES and for the wider CCG commissioned extended access service will fund a single, combined access offer as an integral part of the Network Contract DES, delivered to 100% of patients including through digital services like the NHS App.

25. What does this mean, exactly? • We don’t know yet • But could mean 8-8 7/7 access to be a compulsory part of the PCN DES • Sounds like online consults might be possible but might still require face to face and ? Still needs to be GP • Access review currently underway no date for publication but will inform the model • Will an opt out be allowed? Can it be sub-contracted? • Where is the workforce?

26. More complications for dispensingdoctors • As PCNs employ more and more staff - case for a limited liability vehicle to employ them becomes stronger and stronger • This will endanger dispensing rights • If extended/improved access provided through hubs or subcontracted -risk of loss dispensing income • Review of out of area payments and digital provision -could open rural areas to more competition (or could restrict that) • If a patent registers with online provider then reregisters with you and you have historic rights you lose the ability to dispense unless they change address • No mention of dispensing doctors at all in the Five Year GP contract framework or NHS Long Term Plan

27. To dispense to a patient They must be registered with your practice. (full or temporary) You must have dispensing rights for them Be aware if hub provision of services

28. Other newcontractissues for dispensingdoctors “all practices will be offering and promoting electronic ordering of repeat prescriptions and using electronic repeat dispensing for all patients for whom it is clinically appropriate, as a default from April 2019.” Dispensing doctors can do this just like other practices What about EPS? Slightly different but still no EPS solution for dispensing doctors so not compulsory until it is - but this will surely come.

29. Other newcontractissues • On line booking for 25% appointments • Use of NHS App -beware of adverts for online pharmacy and ensure your dispensing services are clearly offered as a “choice” • 111 booking direct (if you have multi-site operation danger dispensing patients being directed to non dispensing sites) • Video and online consultations -do these qualify for dispensing rights if delivered from a remote non approved location? or a subcontracted non dispensing provider. • Answer - you can dispense to your patients even if “seen” by another doctor • Prescriptions issued by PCN staff (pharmacists) - you can dispense to your patients but check whose account they are charged to.

30. Other newcontractissues • Rurality payments only paid for those patients in your practice area • London weighting only paid to patients living in London not just registered there • (both these are antidotes to anomalies for digital providers) • But consultation under way on digital provision and out of area payments • One option is forcing providers to open premises if they register >1000 patients in an area (could provide back door opening to controlled localities) - NHSE have signalled intention to implement this from 2020 • Once again Carr Hill and rural weightings may be reviewed for 2020

31. PCNs accountablefor deliveringprimarycare in future? • Look at this question from digital first consultation • “Alongside these potential changes, do you agree that PCNs could become the default means to maintain primary care provision, thus removing the need for most local APMS procurements?” • Could this mean PCNs are the ones to ensure ongoing GP provision instead of CCGs and NHSE e.g. with contract handbacks? • Or just invited to have first refusal before a contract is put out to tender? • Response to consultation stated NHSE would establish list of approved providers to take over these APMS contracts -so not for PCNs yet!

32. But what about the workforce? • We have a NHS Long Term Plan but no workforce plan • Critical shortage of GPs and practice nurses in particular • Potential surplus of pharmacists but only in certain areas and are they willing to work in PCNs? • Social prescribers not an issue as no professional qualification as such, so many eligible • What about paramedics, first contact physios and physician’s assistants

33. Statement in contractdocuments 1.18 The roles have been chosen by NHS England and GPC England for four pragmatic reasons: (i) we estimate that we can get enough supply (ii) we see strong practice demand (iii) the tasks they perform help reduce GP workload, improve practice efficiency and deliver NHS Long Term Plan objectives (iv) they are relatively new roles, where it is possible to demonstrate additional capacity, unlike GPs and practice nurses.

34. My FOI Request to NHSE 14/03/19 Please can NHSE supply the evidence on which “the estimate we can get enough supply” is based (or provide links to appropriate documents if already in the public domain) for each of the four clinical specialities Clinical Pharmacists, Physician Associates, Paramedics and first contact physiotherapists. Please can NHSE disclose any details of how any assumptions of how many whole time equivalents in these four specialities will choose to work in Primary care Networks (as opposed to secondary care or other sectors )has been based. Please can NHSE state if any modelling of the regional availability of such new workers has been made and if so publish the details Please can NHSE state if any risk assessment has been conducted as to the possibility there will be not enough of such professionals available. And if there has been such risk assessment to publish it . Please can NHSE state that if a Primary Care Network is unable to recruit the above professionals does the money identified for reimbursement remain with the local CCG or is returned to the NHSE or any other body.

35. Their response “NHSE England does not hold this information” “You may want to redirect your request to HEE” Despite a request for an internal review of this FOI request as they have not answered the questions - no review taken place and they state no statutory timeline for this! So unless they tell me otherwise, they have no evidence they have considered any of my questions! But we do know unspent funds revert to CCG now

36. Unused additionalrolesreimbursement • Cannot be carried forward to the following year • Cannot be used on any staff other than those defined in the DES • Can be used to fund additional pharmacist or link workers appointments for 2020 -2021 brought forward into 2019-2020 • (but need to be sure of reimbursements first, and moves to weighted capitation next year) • If funding unused reverts to CCG for potential offer to other PCNS • (suggest invite LMC to work with CCG to devise a fair and transparent process)

37. PCNs and investment, the fundingdilemma • Much of the new money is related to reimbursing staff • If you cannot find the staff you lose the money but keep the work specified in the DES! • The staff groups are not necessarily what you need most (GPs and nurses/nurse practitioners) • Shortages have already driven the price of pharmacists beyond what is reimbursable, will the same happen for the others? • A lot of what is specified to be delivered can’t be done by the new staff • So in a workforce poor environment is this a good deal?

38. Core contractchanges • These are guaranteed and available for you to spend as you wish • £1.76 per patient if you take up the PCN DES • Indemnity fees now gone for all NHS work for you and staff • Year on year increases in baseline funding • 2019-2020 1.4% , 2020-2021 2.3%, 2021-2022 2.8% • 2022-2023 2.5% ,2023-2024 2.7% • So consider do you need the monies from PCNS?

39. Staying in or leaving a PCN • Remember that (for now) they are voluntary • If you leave you lose the £1.76 per patient but…. • You lose the extra work encapsulated in the PCN DES specification • This year -no brainer but next year it could be considerable • And in 2021 could mean 8-8 7/7 (but with more cash) • You may lose some enhanced services -but how many of these make a profit? • IF you can’t find the staff - savings from not employing them will offset the losses

40. Life without a PCN • If you don’t do the enhanced services who will PCN look to provide them? • Unless they can easily access staff would they could come back to you? • You can then decide what you WANT to provide • And lose the accountability for doing the bits you don’t or can’t • But if neighbouring practices leave the PCN and you stay in -you become accountable for DES work for their patients too • What is an entire PCN opts out? Who does the work then?

41. In summary…Are PCNs the vehicle to save generalpractice and improvepatientcare…. … Or the new fall guys to be blamed for its failure after NHSE and CCGs have failed?

42. If You can get and keep the staff for the reimbursablecosts -probably yes If you cannot -probably not

43. Watch outfor… • Employing staff and committing to redundancy for whole NHS service -ensure you have a potential exit plan from the PCN • Employing staff who need loads of extra training -e.g non prescribing pharmacists • Explore opportunity and real costs of any supervision from others and training needed. • Training folk up only for them to be poached by others • Price inflation in a workforce shortage and paying more than reimbursable costs • Risks of employment and tribunals -ensure PCN agreement shares the risk out.

44. Watch outfor… • Loss of commercial intelligence to community pharmacy if they become a statuary part of your PCN • Direct competition with community pharmacy • CCG mergers and PMS and ICS financial position • Changes to enhanced services contracts -now through PCNs • PCN funding moving to weighted capitation next year • Acute trusts looking to phagocytose PCNs • Any changes to funding formulae

45. Watch outfor… • Losing dispensing rights through merger, incorporation, change in premises or sub contracting • Loss of dispensing income through change in provision • Committing to PCN beyond date the DES specification is published -how can you stay committed to something you don’t what is entailed , planned date publication DES end of February 2020! • Thus break clause should reflect c. 3 months or time from date of publication of DES specifications to year start whichever is the shortest • Potential future legislative changes

46. And, finally… • Remember a five year contract lasts as long as the government which negotiated it. • Politics can change everything -is dispensing safe long term? • Will PCNs become compulsory? • In my career I have seen fundholding, PCGs,PCTs,PBC,CCGs and now PCNs -these structures don’t last forever • But as partnerships you have unlimited liability • Protect your core contract, dispensing rights and liabilities from PCNs as much as you can

47. Maybe Consider PCNS Like Buying Shares • What is the outlay and what is the likely return? • Are they likely to bring you extra income? or reduce your workload or improve quality of life? • Will they improve services and care to patients? • What are the risks of losses (money and staff time)? • Can you spread your risk? • Are they inevitable? • So Buy/sell/hold or watch?