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2020 Vision

Friday 3 January 2020

'Twas two nights before Christmas, when all through the house
Not a creature was stirring, not even a mouse
My laptop was open and at the screen I’d stare
In hopes that the Network specs soon would be there;

I’ve seen the future, and it’s Networks. In case you hadn’t heard, the Primary Care Network (PCN) Service Specifications arrived with us, in draft form, on the 23rd December, and we have until the 15th January to respond. I’m not going into huge detail about them here but would encourage everybody to read and digest them, and after a gentle eructation, respond as appropriate. Specifications themselves can be found here and Barry’s excellent and comprehensive commentary here.

There are several notable things about these draft specifications. It feels extraordinary that at the time of writing we’ve still heard very little about them from our negotiators, the General Practitioners Committee (GPC) of the BMA. The stated aim of the 42-page document is to provide the PCNs, community service providers, wider system partners and the public (who probably all have better things to do at this time of year) with a chance to comment on the outline before a final version is published, purportedly in time for April. How strong is the GPC negotiating position, and maybe we even need to ask what their role is, if other ’system partners’ will have a significant say in the drafting of the final specifications?

This is the crucial point: unlike the usual Enhanced Service specs that we’re used to reading, they don’t represent direct payment for delivering services (practices would run for the hills if asked to deliver all that’s in these specs for the funding on offer), but rather funding through reimbursement for additional workforce roles enabling the PCNs to deliver the specifications listed. It’s all dependent on PCNs employing staff, which would need to be happening very soon, like now. The anticipation is that there will be 6000 additional staff employed by 2020/21, rising to more than 20,000 in 2023/24. For a PCN with 50,000 patients, that equates to five additional staff in 2020/21, rising to 16 over the next three years. How many extra has yours got so far?

Primary Care in some parts is already on its knees, and the preamble to the document suggests that developing the PCNs is going to ease the load on Primary Care rather than add to it, and that these notional souls will soon be able to provide some relief for GPs under the cosh, stating that they ‘would provide more than sufficient capacity to deliver the requirements across all five services with significant capacity remaining for these additional roles to provide wider support to GP workforce pressures by handing appointments or queries that would otherwise have been the responsibly (sic) of the GP’. A quaint notion, but, I’m afraid, complete tosh.

In England 99% of the practices are enrolled in 1250 Networks (PCNs) across the country. There’s already huge variation in the make-up, size, geography and maturity of the PCNs. Some of the services to be introduced via the network contract will already have been commissioned in certain areas by proactive CCGs. How is that funding going to be redistributed within Primary and Community Care (as the specification states should happen) without destabilising those practices? How exactly is all this going to run alongside, and tie in with, the core GP contract?

The paper acknowledges the colossal inequity of funding for Primary and Community Care and professes (at least) the aim to increase the proportion of the budget going to these sectors. The world and his wife have been looking at PCN development as the great system saviour, and it’s encouraging that this is recognised as being unrealistic in the document.

The five specifications include: Structured Medications Reviews (SMRs) and Optimisation, Enhanced Health in Care Homes (EHCH), Anticipatory Care, Personalised Care and Supporting Early Cancer Diagnosis. Each will be developed over the next three years, but two (SMRs and EHCH) are to be delivered in full from this April. There will be considerable overlap between the specifications, and two of them, the EHCH and Anticipatory Care, are to be developed and provided jointly with Community providers (with their NHS standard contracts amended to reflect this). Somerset should benefit from the joint working already happening here, such as the Alliance Trust having a combined Primary and Community Care Directorate in place, and hopefully they can build on schemes such as the successful LARCH project providing in-reach support to care homes in the west of the county, and similar programmes to the east.

The specifications raise lots of questions that need addressing. For example, the EHCH part specifies a ward-round each week, in every residential and nursing home, with the GP (or possibly community geriatrician) appearing at least fortnightly. Who is funding that? How does that sit with privately run care-homes? All the specs require that each PCN has a clinical lead for each of them, thankfully not necessarily a doctor, but that alone feels a big ask when everybody has their backs to the wall.

In short, it’s complicated. It’s another of those fizzing bombs that NHSE thought best to lob onto our desktops on the 23rd December. If every one of us was to read the paper and reply in longhand and green ink in the next week or so, it sounds a mite optimistic to have the final specification ready for April 1st, unless, heaven forbid, it’s just a token consultation. We’ll see.

Depending on the length of your teeth, you might remember 20 years ago today- January 3rd, 2000. It was a Monday, and many of us were returning to our desks after the New Year break and turning on our computers with trepidation. The fact that the earth hadn’t stopped spinning and we hadn’t been rained on by plummeting airliners on the stroke of New Year had given us hope that the Millennium or ‘Y2K’ Bug, which had been predicted to cause all manner of chaos might have been over-hyped. I’d flinched as I pushed the power button, anticipating instant cyber-meltdown. We’ve had twenty years of IT development since then, and last Saturday first thing a bit of instant anything would have been nice as I cranked up my surgery desktop. It took 25 minutes and several cycles of configuring/wheezing/updating before it gave up completely. At least it gave me a chance to wish those very nice people in IT support the compliments of the season.

We talk a lot in the office about practice resilience, and fully appreciate that our Practice Managers and their deputies are vital cogs in the smooth running of the machine. There is an LMC day for managers (‘Managing Your Resilience’) on February 13th at Taunton Rugby Club. Jill and Mandy have secured some excellent speakers including Bridget Sampson, the Managing Partner from St Austell Healthcare, whom some of us met at the PCN event in November. Primary healthcare had collapsed there, and she played a central role in getting practices working together and revolutionising the way services were delivered, effectively as a network. Yvonne Vigar is well-known to us having worked for the old PCT and more recently providing excellent training support for the LMC. There is scheduled to be a session from the PCSE (tin hats optional) and the day rounded off by the excellent Dr Phil Hammond, who will be guaranteed to send everybody home with a smile on their face, or something.

Tuesday is my habitual duty day and so I copped a packet this year, covering Christmas Eve until closing time and having a busy New Year’s Eve. This was my last Christmas in harness, and I actually enjoy working between Christmas and New Year- the punters are always grateful to be seen, and there are fewer distractions than usual, especially as the LMC/CCG/NHSE traffic is usually minimal.

I missed my practice Secret Santa on Christmas Eve as I was visiting our most distal Nursing Home to admit one of my favourite elderly patients. I’d first met him and his wife 30 years ago and we’d been through a lot together. Of the couple, he’d always had the more colourful medical history, but had been widowed suddenly a few years ago. He was a perfect gentleman and always grateful for everything that he had and the care he received.

I genuinely can’t recall the last patient I admitted from a care home, but he had only been there for a spell of respite care, and was waving a few sepsis flags, not evident when he’d been seen by the excellent complex care team the previous day. They had carried out just the sort of comprehensive assessment proposed under the new PCN ‘Enhanced Health in Care Homes’ service spec. mentioned earlier, and if nothing else it proves that people will still ‘go off’ quickly and unexpectedly and need admission. I was saddened to hear that ‘nice Mr. XX’, as he was known amongst the partners, had died just before New Year. It felt like the end of an era to me.

2020 promises to be big year for all of us, so tear down the decorations, brace yourselves, and bring it on.

Nick (squinting at the Horizon)

PS - I eventually had my Secret Santa- a pile of reading glasses (I lose lots), all the better to read NHS small print with.

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