Improving the Primary Care Network DES Service Specification

Improving the Primary Care Network DES Service Specification

Check out my original review where I went through the DES: here–https://youtu.be/K1qwyxt63f0

Declaration – I am not involved in the negotiations. I am Nottingham City East PCN Clinical director but these are my own thoughts. For some backstory in 2015 I wrote a further Blueprint for Primary care : https://egplearning.co.uk/a-further-blueprint-for-primary-care/ with a colleague as Jeremy Hunt launched the five year forward view. Some of these aims have been achieved (indemnity) but much can still be done. 

How to improve the DES- I will talk firstly about general changes and the headline points. Then each specification in turn with my more innovative (controversial) ideas at the end.

Ethos

The release time of the specification has caused a lot of frustration. Even more so in the first webinar where little engagement was offered, just reading the spec. This led in part to one CD resigning live. NHSE doing an open consultation on the draft is a good thing. Feigning listening is not. 

At points, the specification makes reference to evidence. In particular vanguard projects. However, it neglects to mention that vanguard projects have had significantly higher levels of funding for each aspect and therefore converting this to specifications for networks to follow is a fallacy. 

You cant use a recipe that feeds four people that costs £10 and say provide the same meal for £2 all the time – even with using foodbanks. 

The original outline of the DES was to stabilise primary care. This draft does not do this but further destabilises it by utilising the additional roles above the capacity of work the can create and negates the fact networks will be part-funding them. This was a poor way to show that NHSE/I was listening to the needs of general practice. Many comment the draft is intentionally too far to the right to allow any softening to be accepted as better than the original. This is a skeptics dream. 

For this process to work- show General Practice that NHSE is truly listening. Much of this has been done amazingly by Dr Nikki Kanani and I do not envy her position. I am mindful of ‘do not shoot the messenger’ being very apt here. 

Let’s move on. The following is a combination of my views and those from the various forums I engage in. 

Trust 

General practice. If I had control I would keep existing structures that could help foster better collaborative working and simply offer the resources to networks to use for their local area. 

General Practice has proved to be the most cost-effective method of delivering healthcare currently doing 90% of the NHS workload for less than 9% of the funding. Trust the networks to deliver primary care with the simple metric of improving the health of the network population. 

Ideally to fund the global sum but if not, then to the networks directly to use as they seem fit, to provide roles or services for better patient care along the 5 categories as best for their population. 

However, we do not live in a world of trust despite GPs consistently being the most trusted role in the country. 

So if working towards the confines of adjusting the existing DES and its specification let us have a look. 

Worth looking at the Berkshire, Buckinghamshire and Oxfordshire LMC document link: https://drive.google.com/file/d/1Bj7hkuCQasbXs-Mk7MOKpDq-lfjl3YSK/view?usp=sharing

This outlines workload implications and makes the case for each average practice to lose £100k over the term of the network DES. My thoughts do align with some of this document, however, I do not agree with the principle of withdrawing from the DES at this point as this is still a draft version and the final specs may differ. It also does not include AFAIK  the overlap of patients in the DES which would reduce some of the work. 

Other LMCs and organisations have also been verbal on their views including GPSurvival who have started a formal petition about the service specifications.

See this link.: https://docs.google.com/forms/d/1uUa25fyz1Y8vCNTXP17pDvi3G26NQ1q8iOp64P0vfw8/viewform?fbclid=IwAR1w6EGJZ86AtuFWDafMWlXCRPAILHGHHkrs8ElqCQgGSiyodmCajhwfC78&edit_requested=true

DOI I am the treasurer of GPSurvival. 

Headline improvements

Time:

• Delay the specifications. The timelines for agreeing on the spec, the short consultation time and the level of response has shown the draft spec is way off the mark. Take a breath and take a while longer to action this. Aim for a June Launch as per the start of the DES with networks able to look at funding from April for the ARRS. 
• Clarify the specification before releasing them. The above will allow time for the spec to be clear, unlike several lines in anticipatory and personalisation which are ‘to be confirmed’. This does not instill confidence that goalposts may change again – do not do this. 
• Stratify the spec for a category a year rather than two in year one with the others to run parallel. Let the network decide which, to begin with as they can adapt to what local services can focus on. If one had to be chosen first given the current ARRS and recruitment options looking at the SMRs first may be an option. 
• Solve interoperability and IT. Many of the metrics and outcomes are based on the interoperability of IT systems within primary care and between primary care and other sectors. Fix this first then ask for more. At present we can not explore a digital hub as the IT systems do not allow EPS prescriptions from a hub model. Our community teams are on fragmented systems that do not talk with our complicating care. This duplicates and complicates healthcare and needs resolution to enable effective care.
• Reduce the metrics. With over 30 metrics, keeping track and monitoring them alone will be a challenge. Simplify and reduce these to one or two per spec, or let the networks decide the metrics that are important to their population.

Funding

• Remove the requirement that funding can only be used for additional roles. In many places, other ways of funding care may be more useful such as systems to engage with patients, nursing roles, estate management – let the network truly decide how to spend its funds
• If this is not possible, open the funding to all roles and not specified ones so networks can recruit the workforce they need rather than what others think they may need. If the GP role is still not acceptable then roles like nursing, occupational therapists, pharmacy technicians, and data analysts. 
• Remove the 70/30 split and fully fund the additional roles from NHSE/I. This will reduce the available workforce but would answer the issue of local practices having to supplement the roles and mean they can do work greater specified by the spec. 
• Remove the necessity for named clinical leads for each spec. If this is a red line then fund them appropriately similar to the clinical director role. Assuming the CD role can do this is false and sharing the funding is not an option to have an effective CD. 
• If a red line then allow the leads to work across networks. In Nottingham city, we have a close working of a network of networks and the option to share these lead roles across multiple networks is more achievable than each network finding 5 people – however, the draft spec prohibits this. 

SMR

Looked at this in my area. Patients on 10+ meds alone was about 5% practice population. 

• Clarify what ‘significantly longer than a routine GP appointment’ is. This line is used to explain how long an SMR would be. Is this 15 mins, 20 mins, 30 mins, and hour? This has clear implications on workload and should be clarified if this area is to be monitored. 
• Do not specify that the review has to be by a prescriber. Many practice and network pharmacists and chronic disease nurses may not have independent prescribing rights yet and this puts a significant burden on training times and availability. This then pushes the work back to GPs adding to the workload. This also would eliminate innovation such as using community pharmacy colleagues from supporting this work and makes a mockery of the MURS programme of recent years. 
• Make SMRs a paid for service. Given this is an extra service above that offered by primary care with no additional funding – allow practices to charge for them commensurate to the workload involved to offer higher quality of care. This can be commissioned by local CCGs or patients. 
• Align SMRs with QoF to prevent duplication of work. This would allow funding for the work to be evident but reduce the burden of work on practices while still offering effective care from a national perspective. 
• Clarify how patients may be contacted for SMRs. Ensure that written communication is clarified to include digital means such as notifications or texts as this is unclear and would further help with reducing climate impact and sensible patient flow. 

EHCH

This specification could have been effective but its prescriptive and ludicrous nature truly raises questions about the aims of the specs. It outlines a staggering increase in workload and specifies being led by roles not funded in the DES ad only on a F2F basis. It also is discriminatory to frail patients who live in their own home. 

To improve it:

• Do not use location or age as the denominator of healthcare need as these may not be good predictors for individual patients. Use validated metrics such on frailty instead to capture patients in and out of nursing homes. 
• Remove the ridiculous premise that a GP/ geriatric consultant must lead the team. Allow the network to source the role best suited based on local recruitment availability in need. 
• Remove pedantic requirements of weekly/ fortnightly visits. Let the network decide the frequency needed to offer appropriate care to its population
• Remove the requirement for care to be only face to face. Allow the increasing use of digital consultations to flourish and be effective. This can be by direct video consultation supported by the home, or with assisted clinicians as a virtual ward round. Additionally, allow for funding to be used to facilitate this. Ie a simple webcam like the logitech C920 HD in each nursing home would work effectively on a Zoom system for a basic telemedicine ward round.
  Logitech C920 HD: https://amzn.to/2R7BbTw
  Zoom: https://bit.ly/eGPlearningZoom
• Review the spread of NH in PCNs. The requirement that NHS are aligned to PCNs while seemingly sensible proposes significant challenges. Nursing homes traditionally are denser in areas of low land cost ie more deprived or secluded areas. This can create a significant imbalance.  In Nottingham city, Two PCNs have the majority of nursing homes in their network areas. One network has 24 care homes, double that of all the others and is not the largest network. This creates a clear funding deficit to deliver the outlined level of care and WILL DESTABILISE this network (it is not mine – we are next down the list at 12 care homes). 
• Make these reviews paid for service. Several areas of the country already have care homes paying additional to practices to offer an extra level of care above the GMS contract. This aspect of the DES will remove that element. Given an existing precedent, one suggestion is to make this service paid for service to allow the funding to occur. This can be commissioned either by the CCGs or care homes.
  
  

Anticipatory Care

Anticipatory care is manageable pending relationships with ICS, CCGs and ICPs, and if appropriate tools exist to support the population-based care. I will admit my knowledge gap in this area which leads me to my first improvement. 

• Push back the time frames to allow all networks to develop the local links and priorities. This is a simple fix as with more time much more of this aim is likely to be possible due to its synergy with the EHCH. 
• Be specific over the monitoring aspects at the outset. Several aspects of this spec are ‘to be confirmed’. As mentioned earlier this is not acceptable as it indicates a possibility of shifting goalposts or more work if not in the correct format. Start as you mean to go on. 
• Clarify the responsibility of who is paying for the tools. This spec mentions several tools that could be used, some of which are beyond the scope of a PCN to access individually. A clear direction on the responsibility of the cost of these tools needs to be established. In many areas, the PCNs are viewed as the solution to all the problems in primary care. NHS England needs to ensure they are not overburdened with destabilising costs and responsibilities due to poorly worded contracts. 
• Clarify the evidence behind using care plans and the need for monitoring delirium assessments etc. This is not provided in the DES specification document and if no evidence that these care plans and assessments lead to an impact on the reduction of clinician workload and/ or patient demand then they should be removed and replaced with something that does. 

Personalised Care

I mentioned in my first video this harkens back to the failed unplanned admissions DES for a few years back. The reliance on care plans and monitoring are lessons still not learned. However, this is the first mention of tackling inequality – albeit on a minor scale. 

• If personal health budgets are to be continued and monitored – offer national training to all with a public campaign to education patients rather than passing this cost to networks. I have limited knowledge of patient health budgets. Again no evidence is offered in the document of their impact or effectiveness but this seems more like a public health priority funneled into the DES. Remove or support nationally with education and training. A national website checklist would offer many patients the correct information and evaluate more effectively than spending clinician time doing an administrative task. 
• Remove the target for social prescriber referrals. A target is not necessary for a role billed to have a significant impact on care. 
• Clarify which PAM is to be used – 100 vs 22 vs 13 point version. A clear difference in workload and monitoring outcomes based on these. 
• Clarify the monitoring requirements at the outset as per earlier specifications. 
• Remove the metrics. The metrics for this specification are vague and talk about quality- something that is hard to measure when you do not know what the test is. Given the DES is metric heavy simply remove these and replace them with either trust as per earlier or linked population-based outcomes like reduction in amputations in diabetic patients, reduced hospital stays in frail patients – essentially let the networks decide their metric for their populations. 

Supporting early cancer diagnosis

Much of this specification I find sensible in its aims. My only question is the time needed to action it given the repeat requirements for a lead and oversight. 

• Provide data analyst support for networks to look at their data. This would help clarify how networks can proceed based on evidence. This could be provided locally by CCGs/ ICS etc, but do not make networks hunt for this. Provide universal validated metrics so that shared learning can occur.
• Provide social media engagement and community education sessions to networks. Much of the strength of this specification is mobilising the community. This can be achieved with face time with the community outside the confines or practices and via local media and social media. Provide networks with the tools to do this. 
• Provide translation services support. One key challenge is non-English speaking cohorts. Given CQCs hate for Google Translate as a tool, provide support and resources for networks to use to convert resources into other languages to support their networks ie bowel screening videos in Polish or Vietnamese languages. 
• Clarify the safety net metric. This metric is unclear to me no matter how many times I read it. How will this be monitored?

Radical changes

So that is my suggestions for adaptations for the specifications. But what if we were rewriting it? These are suggestions for NHS England which are in their domain to consider but not covered in the existing DES. 

• Create a national acute visiting service (AVS). Using the funding for ARRS share working on how to deliver a footprint wide AVS using roles such as physician associates and paramedics that can release GPs to offer care to patients while providing equity across the country. Ideas like those of Dr Paul Bennet as shown in the General Practice Podcast could be adapted across the entire country : https://ockham.healthcare/innovation-in-general-practice-time-saving-begins-at-home/
• Create a national formulary. This would help prevent variation and align purchasing to tackle supply issues and allow larger bulk buying for medication supplies. 
• Charge for all prescriptions or charge for none. This would have the plastic bag effect for the need for items on prescription at reduced cost ie £1 per item with pre-payment certificates being an option for all. Bring in equity- charge for all or charge for none. 
• Re-design prescription exemption process. It is ridiculous that a patient with one specific chronic health condition can have all prescriptions free for life, but a patient with a more acute on chronic condition like COPD or asthma is not eligible which will cause greater acute damage to the patient and cost to the system via an admission. At least update the prescriptions to reflect modern times ie universal credit as an exemption so patients are not committing fraud, or adjust the age limits in line with national pension age. 
• National self-care for health and finance education programme. Many patients expect the health care system of old -today. A national education programme both in schools and a public campaign identifying the new roles and how to use our NHS effectively would have a greater impact than requiring each area to generate the same resources several times over. Created and delivered centrally offers the uniform message and cheaper costs to deliver public level education about how to use our NHS and how to manage your health responsibility including services. Adding finance at the same time is just further cost-saving. 
• A national campaign to use NHS app. The NHS app is meant to be the doorway to our NHS and the focus of our digital healthcare revolution. However central support for its use is lacking and limited in information – even for a techy like me. A targeted approach with resources and support (again in multiple languages) could deliver a much-needed kickstart to the digital push we need. 
• Equal funded clinical director (CD) time for all networks. The CD roles are based on network size. While there is some logic to larger networks needing more time, it is evident that one session a week for smaller networks is a drop in the ocean. Offer equal CD funding to all networks ie three-session up to 75k patient population size and 4 sessions over that. 

What do you think?

Which did you think were sensible and which did you think were lunacy?

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