My review of the 2019 Primary Care Network Service Specification- the good, the bad and the confusing.
This is the live recorded review of the draft primary care network service specification.
To see the document in full use this link.
Below is the draft version of my notes.
My perspective on the primary care network service specs
Cover the good, the bad and the confusing.
Check out my PCN resources and General practitioner playlist (in show notes)
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Why I am talking about this -- am a GP also PCN director of NCE -- 66k patients in a deprived area of Nottingham.
Firstly the timing of the documents
Release of specs day before Xmas eve- while aware impacted by the election, purdah and process, it speaks to the perception that when PCN CDs work is irrelevant to NHS England.
However, I commend Nikki Kanani’s engagement on SoMe and the will to gain feedback before making the spec official,
as well as engagement events beforehand (twitter chat and webinars)
So emphasis that this is draft specifications and can be changed. So let us take a look…..
The document starts by talking about the investment being offered. While there is a significant increase in funding being offered, it is important to note the UK still invests less than most other western countries especially in the G8 at about $1000 less per person.
It also mentions a 5-year contract. I would like to mention that it is not really a 5y contract but a 5y agreement of the funds. If it was a contract the terms would be clear from the start. Instead, we are having ongoing annual negotiations of the requirements -- which is no different to what we have been exposed to in primary care.
It then identifies seven asks or as they have been locally called the significant seven of which five are to start from April 2020 and another two from April 2021
- Structured Medication Reviews and Optimisation •
- Enhanced Health in Care Homes (jointly with community services providers) •
- Anticipatory Care (jointly with community services providers) •
- Personalised Care; and •
- Supporting Early Cancer Diagnosis
1.8 When will we have clarity on the process and use of the Network Dashboard?
1.11 Funding is not allocated directly for the delivery of the service specifications -- let that sink in.
1.12 Extra capacity from the new roles in 20/21 -- much of this was promised to stabilise practices not ask them to do more and does not allow for the extra 30% investment which is not supported by the existing pots.
1.16 funding for community service providers commented -- limited detail and asking us to agree based on limited responsibility awareness
1.17 Structured med reviews and EHCH from 20/21 other specs over 5 years.
1.18 There is overlap between the specs, especially with the EHCH aspect.
1.24 ‘Funding previously invested by CCGs in local service provision which is delivered through national specifications in 2020/21 should be reinvested within primary medical care and community services’ key line to be noted in regions
Structured medication review optimisation
Ideal to improve quality which may impact workload and a key target area for network pharmacists.
Noted they recommend longer apts than standard GP appointment and keen to understand where this time will come from, and a focus on the switch to low carbon inhalers.
There are comments about primary care organising the majority of prescriptions but no comment on secondary care variation and impact on prescription choice. Should we not move to a national formulary rather than regional variation which may help with supply issues.
2.6 looks at reducing GP appointments, but structured reviews do not reduce the number of primary care appointments but it may improve the quality of care. These are two different things.
2.11 the line about SMR apt being longer than an average GP appointment. This means it is not cost-effective and not within the envelope of the funding being offered. PSSRU data puts currently at £39 per 9.22min consultation and a band 7 nurse (no pharmacist data) at £55 per hour compared to over £200 for a GP.
2.15 What Funding is there for lead?
Would this be part of the prescribing QoF for 20/21 or in addition?
Confusing: ‘written communication to patients invited for an SMR, detailing the process and intention of the appointment’ to clarify the term written as many can interpret this as paper. With increasing digital use, reducing carbon waste etc this needs clarification to include digital. Also, why is spoken not acceptable as an explanation at new patient check with a hca may have a much better impact?
A focus on medicines of low priority- this still requires a national approach and guidance on complaints about when medications are appropriately recommended or not -- given the workload and implications this has -- especially in deprived areas where this creates challenge and conflict.
Would a better option be to have a review of prescription exemptions and eligibility for free prescriptions? In deprived areas medication poverty exists for those who work but can not afford their medications when current exclusions mean a patient with a slightly low acting thyroid can have all medications for free but a patient with brittle asthma, high risk of urgent deterioration can not have their inhalers for free.
How this discussion moves forward is for wider debate but should all scripts be charged a nominal fee like the plastic bag principle, or all prescriptions free or all OTC meds not available on prescription.
Also talks about community pharmacy involvement and this replacing the MURs would be an option -- but only likely truly effective if community pharmacies have access to the GP notes- a key data-sharing issue.
The proposed metrics are actually very sensible and clear patient benefit and practice outcomes if funded appropriately.
I would ask that an additional metric looks at the workload created by brand switching in primary care from cost saving as well as supply issues which may support the national picture more effectively than medicines of low priority -- this si where local impact with a network-based pharmacy team can improve practice workload and patient service.
EHCH- enhanced health in care home
3.2 comments about patients in care homes being treated with the same support as those living in their own home. So if mobile and ambulatory then these patients should be coming into the surgery and supported by the homes to be brought in rather than practices visiting unless bed-bound hence providing equitable treatment.
3.5 The evidence talked about makes reference to Nottingham’s enhanced care home LES prior to 2017. This was based on two yearly contacts with patients a year with a basic monitoring template. This required a once-monthly ward round by a single clinician for a near 10k practice population with about 50 care home residents to deliver outcomes that are cited in the paper.
3.8/9 Clarity on the distribution of care homes is key and no specs should be agreed till this is offered. Given the CCGs have limited power to implement this over patient choice it seems almost a faux statement. Also, there is no direction on how finance will be directed to support denser care home areas, which are typically in more deprived areas due to lower land costs.
3.10 four focus areas:
- Enhanced primary care support
- MDT support
- Reablement + rehab
- High-quality end of life dementia care
3.12 bringing OOH provision under the umbrella of PCNs is a complicated process and a clear threat to workload and viability.
3.14 comments about supported living are not part of EHCH yet and 3.15 suggested these could be included in care homes work in future -- a significant increase in work for no commented extra funding at that time. Clarity needed.
3.16.1 where will funding for a clinical lead come from?
3.16.3 offers challenges of registration and the choice agenda. If this is to function then removal of the choice agenda must be considered to align to systems and reduce confusion and risk of complex system care.
3.16.6 This is frankly the worst specification I have seen. A weekly home round that must be led by a GP (or community geriatrician) on a minimum of a fortnightly basis and regular MDT staff.
This obliterates any positive work around skill mix, reinforces the false belief that a GP must coordinate all care, is unfunded for that skill of workforce delivery on this scale and negates the option of using digital methods to support innovative care.
Mandating GP time doesn’t account either for the cost -- at a minimum of one session, a week of GP time is about 10-12k incl on costs outside of London which is not supported by the DES funding so must be found by the practices. This will also vary if a higher number of patients in each network.
Whoever created this specification needs firing from NHS England.
3.16.7 what is with the obsession over care plans? Seven days within arrival at a care home or post-admission- this will see potential exponential work for the care home staff who should be coordinating this work and the clinical teams supporting them. Surely a better structure is ‘follow the plan from the place of discharge….’ This line does speak to personalisation as per later point and spreads over the SMR as per 3.16.8.
Pcn can, therefore, charge for training delivered to care homes as the mention of funding for this extra work is not mentioned nor comment of cost-sharing.
Care home staff would normally have flu vacs via their GP not via place of work. How will this impact the ordering and storage of vaccines and the cost balance for those practices in the PCN.
3.16.12 All dependent on the GP IT futures and interoperability issues beyond the control of PCNs and should include a line to reflect this.
3.17 the metrics (aside from 4) are reasonable data extractions if you agree with the existing plan. Given I do not then this needs serious consideration.
So for clarity, this is not in respect to end of life care per se as in anticipatory medications but supporting patients with high or complex needs and working towards pre-care. Pushing us further towards doing public health or population health care work in primary care.
4.3 outlines the service three key aims:
- Benefitting patient with complex needs (and carers) to stay healthier
- Reduce reactive care for specific health groups
- Better interface of care in and around the health systems
4.4 This is done by population segmentation, tools and MDTs.
4.6 a standardised approach is planned but not clear yet -- this is concerning as if you action some great work and this does not align with the ‘standardised plan’ at a future goal post moving date then this risks further frustration and conflict.
4.8 requires working with ICS/ CCG ie areas on respiratory disease if high prevalence in your area or during winter periods.
4.12.1 Again -- funding for the clinical lead role. Who is paying for the population tool if no local access / will ICS be asking networks to contribute to the cost?
4.12.2 Will we have a unified data sharing template offered rather than each networking creating the structure. Are the existing data-sharing agreements acceptable for this purpose?
Who will be holding the liability of these data sets given most PCNs are not formal entities unless a LTD company?
4.12.3 Sounds similar to the unplanned admission DES
4.12.4 another MDT being created. Should there be one MDT that does this and EHCH and directs SMRs too?
4.12.5 The timeframe to deliver comprehensive needs reviews in these anticipatory patients is very short.
4.13 the final metrics again should be a quick pull of the dataset if appropriate coding tools are offered in time rather than each area creating their own. I do think the delirium risk assessment is not suitable for all these patients and already counted in the EHCH. Also benchmarking falls risks may assume a more elderly population. If your local need is focused on more mental health issues then this may point to a younger population.
Looking at a reduction in attendance in primary care and/or admissions may be a better metric for this group pending the cohort reason chosen.
This crosses over with anticipatory care but moves to an individual basis over anticipatory care which is more population-based.
5.2 first mention of health inequalities in the document with a focus on the reduction of unplanned care.
5.4 signposting to social prescribers having a key role in this area.
5.5 Lists the 6 points of the comprehensive model for personalised care.
- Shared decision making
- Personalised care and support planning
- Enabling choice, including legal rights to choose
- Social prescribing and community-based support
- Supported self-management
- Personal health budgets (PHBs) and integrated personal budgets
5.6 Graduated increase in patient selection and outcomes working up to the unplanned admission DES level of workload starting at 5-10/1000 in 20/21 to 20-25/1000 in 23/24 and repeatedly comments additional situations to be confirmed- not inspiring. There is also a focus on msk based shared decision making ie use of FCP and other roles. This could feed into the SMRs for chronic pain suffers.
5.7 another unfunded clinical lead position
5.8 I do not agree with metric 2 and 4 as it is unclear how quality will be measured of personalised care plans and shared decision conversations. Again unifying a metric looking at unplanned care with anticipatory care would be more useful in my eyes.
Supporting Early Cancer diagnosis
6.2 Improving processes will require system integration with ICP partners. I do think taking a local focus on tackling screening programmes is sensible.
Most of this reads sensibly if able to work with ICS and ICP partners. Cross over with QoF plans for next year are sensible but as usual, the devil is in the detail.
6.11 the aims for 21/22 could be clearer ie expanding on safety netting and providing high-quality information on referral is not clear what that relates to ie process of referral, what to do if no contact, documentation, etc. Also with increasing those diagnosed at stage 1 or 2 -- it does not state by how much. While a number is just artefact I would hope there is not an artificial number in the ether.
6.12 yet another unfunded clinical lead position.
The safety netting seems to take away from the patient ownership of their responsibility in their pathway of care -- making us at risk of being more paternalistic. Information provision like videos etc is good but chasing patients is a blurry line.
Improving the outcomes part is further unfunded work as would be in addition to practice-based learning objectives unless combined across a PCN- this requires further admin process which is not funded.
To give feedback you need to use the survey this has the following questions
- Is there anything else that we should consider for inclusion as a requirement in this service? For example, are there approaches that have delivered benefits in your area that you think we should consider for inclusion?
- Are there any aspects of the service requirements that are confusing or could be better clarified?
- What other practical implementation support could CCGs and Integrated Care Systems provide to help support the delivery of the service requirements?
- To what extent do you think that the proposed approach to phasing the service requirements is manageable in your area?
- Do you have any examples of good practice that you can share with other sites to assist with delivering the suggested service requirements?
- Referring to the ‘proposed metrics’ section of each of the services described in this document, which measures do you feel are most important in monitoring the delivery of the specification?
I don’t feel this asks for critical feedback, just positive comments with only question 4 challenging the viability of what we are being asked.
Unfortunately, this does impact my view on NHS England wanting decent feedback.
Also, do you reply as an individual or as a network/ group of networks coordinated in your area ie by the LMC or federations etc?
Aims to improve quality and there is cross over between the parts that make much of it less a challenge than an initial read. However, there is still ALOT of work being asked from networks in a short space of time.
Not funded within the scope of the DES to do so. Either additional funding needs adding or several of the requirements removed and tailed back.
If not significantly adjusted- especially the EHCH part I see many practices leaving the DES making it unviable.
I would not agree to these specs and task our GPC colleagues to work with NHS England to make it more sensible and not something that is renegotiated each year.
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