The government and the NHS have finally published their framework for neighbourhood working. Despite multiple attempts to become positive about the proposed new arrangements, I am struggling to do so because to me the implications for PCNs and practices seem so negative. I will try and explain why.
The document summarises the way the new system will work like this:
‘The ICB contracts a single IHO for an area. The IHO then contracts a number of multi-neighbourhood providers. Each MNP works with multiple SNPs. Each SNP works with all local GP practices in the neighbourhood.’
Even if you are up to date with the new set of acronyms [IHO - integrated care organisations, MNP multi neighbourhood provider, SNP single neighbourhood provider] and can decipher the terms, this feels like layers of complexity are being added above practices and PCNs. The purported intended result is ‘integrating primary, community and specialist services into one seamless system’, but it seems more like dragging PCNs and practices under NHS control.
This new top-down arrangement is likely to feel significantly different for both practices and PCNs, and one suspects it will not be at all comfortable.
Let’s start at the bottom. PCNs are to ‘evolve into’ SNPs. This is to be subject to a consultation, but it does not sound like it is a re-naming exercise. Instead, there is likely to be a mandatory expansion of membership to include a wider range of stakeholders, alongside a transition of existing PCN resources to the new contract holding entity, which may or may not be general practice.
SNPs, it seems, will be the route for all non-core General Medical Services (GMS) money to come to PCNs and practices:
‘SNPs enable primary care to take on new neighbourhood services that are not contracted for through today’s general practice contracts (General Medical Services (GMS), Personal Medical Services (PMS) or Alternative Provider Medical Services (APMS), which will continue to be determined nationally and commissioned locally).’
In addition, while the GMS will continue to be decided upon nationally, contract management responsibility will move from the ICB to the new IHOs, who may well in turn delegate some or all of these responsibilities to MNPs and SNPs.
So potentially all enhanced services (including the PCN DES) will become part of the new neighbourhood contracts, along with contract management responsibility for core general practice.
Alongside control of the money comes responsibility for performance: ‘The SNP contract holder will need to work closely with practices that cover the neighbourhood population to ensure they can deliver care to the registered patient lists of the neighbourhood population.’
A core requirement for neighbourhoods this year is to tackle ‘unwarranted variation’ in access to general practice and to ensure the core hours requirements in the national GMS contract are met. It very much seems that the SNPs will be tasked with ensuring all its member practices are meeting the new standards.
All this means neighbourhoods will potentially control a significant portion of the funding as well as having a performance management responsibility for practices. This is why the new system already feels top down to me and like the NHS is trying to impose its way of working on PCNs and practices.
In the first instance it will be SNPs who will be tasked with performance managing their practices. This will make for some very uncomfortable relationships, particularly given how fractious many PCN/practice relationships already are.
If the SNP is not doing a good enough job of managing its practices then it in turn is likely to be performance managed by the new MNPs, who ‘will have a clear relationship with SNPs and practices, so they too can deliver care to the registered population list across the neighbourhoods they serve’. The freedoms PCNs have enjoyed up until now are likely to quickly become a distant memory.
It doesn’t end there. MNPs in turn will be contractually accountable to IHOs (i.e. be performance managed by them). These have to be NHS organisations, and could very well end up mostly being acute trusts.
So, somehow, we have ended up in a place where GP practices and PCNs are going to be accountable to acute trusts (via several layers of bureaucracy) for their performance, and dependent on them for much of their income.
The one glimmer of hope is that the exact nature of these relationships is all subject to consultation, and so we will have to wait and see how much financial control neighbourhoods are to have over practices and PCNs and the extent of the expectations around performance management. Let’s hope I am overstating it.
Wherever it ends up, PCN leaders will be left with the tough choice of either taking on the SNP that already feels like a poisoned chalice because of how it will impact practice relationships, or letting someone else take it on, which would mean ceding control of both resources and management responsibility to someone from outside general practice. Neither choice feels comfortable.
Ben Gowland is director and principal consultant at Ockham Healthcare, a think tank and consultancy. He was an NHS chief executive for eight years and has also been a director of Croydon Health Services NHS Trust. He established Nene Commissioning, first as a PBC organisation and then as one of the largest CCGs.