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Wessex LMC update February 2019

Date sent: Friday 22 February 2019

Email sent to all GPs, Practice Managers, Nurses and CCG Managers

We have now seen three major pieces of work published in the last 6 weeks:

Individually these would have a significant impact on GPs and their practices but taken together they will have the most significant change that we have seen for many years and potentially even greater than the 2004 contract.

The key issue now is that the commitments detailed in these documents are delivered in full, with the minimum of red tape, so they can truly make a difference to those who work at the coal face and we start to address the issues of workload, workforce and financial risk.

I am sure you will have noticed that there is an alignment between these significant pieces of work. There was a potential risk that these three areas of work operated in silos with the obvious difficulty in potentially conflicting recommendations.  Whereas you will see a number of recommendations that were made in the GP Partnership Review appear in the Primary Care part of the NHS Long Term Plan and/or in the new  GP Contract.

It is important that all GPs understand the changes that are coming, because it will have an impact on us all from the GP Partners, to salaried GPs and Locums as well as Practice Managers and Nurses.

We have organised a series of Roadshows in Wessex. There are 4 events taking place during the last week in February and first week in March.  These will cover the NHS Long Term Plan, the GP Partnership Review and most importantly the GP Contract.

I make no apology that I will, in this email and future ones pick out bits of the contract and try to provide more information and create a better understanding for all. Inevitably there remains many unanswered questions and our understanding is evolving all the time.

If you have any questions please send them to me - I will group them together into themes and then publish some answers because if you have a question you can be sure there will be others with the same question or one that is similar.



1. The future of LMCs

With the introduction of Integrated Care Systems (ICSs) and CCG evolving their role and the development of Primary Care Networks (PCNs) where does that leave the role of the LMC?

2. Primary Care Networks

You will be part of one shortly - how much do you understand about them?

3. State Backed Indemnity

It is finally here but what does it mean?

4. Staff pay

What should you pay your staff next year?

5. Access guidance

This is a document produced by the GPC to help practices.

6. Pensions

How is this issue going to be addressed?

7. Cancer and Primary Care

We do not do as well as other countries in terms of outcomes, how can we change that?


1. The future for LMCs

The Long Term Plan describes that by 2021 the whole of England will have Integrated Care Systems (ICSs) in place - these will evolve from the current STPs and will normally be covered by a single CCG.

In Wessex we have 4 STPs:

So within the next couple of years we could potentially see 4 new organisations form with the role and size of CCGs changing.

The ICS are expected to cover large populations of between one to two million.

We wait to see how things develop but within these ICSs we expect there will be more local or 'place' responsibilities - for example Dorset may work as East, West and Central, Hampshire may divide into South East, South West and North and Wilshire, Swindon and Bath would also need to look at how this would work for them.

It is important that we don't just add another layer of management. The aim is to substantially change the way commissioning is done and move to a system where providers have a much larger stake in the planning, implementation and delivery of care.

We then expect there to be be between 60 - 80 PCNs in Wessex. Each a new organistion with all the needs in terms of support and development.

A question I have asked myself repeatedly is what does this mean for the LMC?

I think these changes will means like general practice the LMC needs to embrace the changes and will need to establish new relationships and work with different organisations but retaining our core functions of supporting GPs and practices, representing them in an ever changing world and ensuring that the potential that is envisaged with the additional investment is realised at a local level.

I believe the future is exciting for the LMC as it is for general practice.


2. Primary Care Networks (PCNs)

Hopefully you are all aware of these and following information that we have distributed to you over the last 12 months you should be aware of the term.  

A Primary Care Network is a geographically based provider of care, based in a community that is led by general practice with the practices at the heart of it. They will normally cover a population of 30-50,000 but in exceptional circumstances could be smaller or larger.

Locally we have Clusters, Neighbourhoods, natural communities, Primary Care Homes or localities all of which could morph into PCNs.

The expectation is that there will be complete coverage of the country by July 2019.

The questions I have been asked repeatedly are:

1. Can the CCG determine the size and make up of our PCN?

2. Why do they have to be geographically based and why is there a population limit of 30-50,000?

3. Can we exclude a local practice because relationships are poor and they will potentially damage our PCN?

4. What are the incentives in terms of joining a network?

5. What happens if we decide not to join the network?

So lets try to address those questions:

1. Can the CCG determine the size and make up of our PCN?

The simple answer is no they can't. There will be a new DES - called the Network Contract DES and as part of this practices will need to detail which practices are involved and also ensure geographical cover. For most of our area these Networks are already established but it is largely for practices to decide who will be involved.

There is a caveat which is the PCNs need to be based in a community because it is expected, with new resources, to take greater responsibility in terms of delivering care to that community, above and beyond the registered list of individual practices. There may be some areas where there are gaps, or practices do not naturally fit into a PCN or there is disagreement, it is then expected that practices will work with the CCG and the LMC to resolve these difficulties.

I have already seen in some parts of the country that the local GP federation has said that they will run the PCN or that the CCG has localities of 100,000+ and already employ staff to work in these localities so the CCG will turn these into PCNs - the answer to both is no. 

Federations may play an important part in delivering care at scale but the PCN is based in a community and configured around practices. The Network Contract DES will be offered to groups of practices.

CCGs cannot 'run' a PCN, they are a provider organisation responsible for delivering care. It is expected that as PCNs evolve that the funding that has been agreed nationally is the baseline and additional resources will be invested in PCNs by CCGs and also STPs.


2. Why do they have to be geographically based and why is there a population limit of 30-50,000?

This is about providing care to a community and also providing additional services at a level greater than an individual practice that would support general practice and be integrated with general practice.

The 30-50,000 has some evidence that it is big enough to have influence in the system and attract others who would want to work with a Network and potentially provide services to the network and small enough to engage and retain local ownership and autonomy.

I expect that adjoining PCNs may well work together in some areas and where Federations are well established they will be working with PCNs when the delivery of care is required at scale. 


3. Can we exclude a local practice because relationships are poor and they will potentially damage our PCN?

The simple answer is no, the population coverage is important and therefore you cannot exclude practices and the additional investment that is being made will hopefully incentivise practices to work together and reduce unwarranted variation.


4. What are the incentives in terms of joining a network?

In Wessex many practices are already working together in communities of 30-50,000 with support from CCGs to try and stabalise and sustain general practice and to improve care for their patients.

I see PCNs as the vehicle that will narrow the ever expanding gap between the specialist generalist, namely the GP and the super specialist who works in the hospital. It will mean more services will be locally based both in terms of some traditional hospital specialities but also community services but more importantly it is the vehicle whereby there will be significant additional investment to support communities, local populations and general practice and to massively expand the workforce.

So by July you will have hopefully established your PCN and signed up to the Network DES.

The PCN will receive funding for 0.2 WTE GP (for a network of 40,000) who will become the Clinical Director of the PCN and in addition there will be £1.50 per patient going to the PCN - so a population of 50,000 will receive £75,000, which it can use to develop, transform or invest in services within the PCN.

Practices will receive a payment for working in a PCN which will be £1.76 per patient.

PCNs will also then have an entitlement next year to funding for Pharmacists and Social Prescribers - which is part of the workforce offer which will potentially fund an additional 22,000 staff working in general practice by 2024.

So year one the focus will be on Pharmacists and Social Prescribers - you will receive 70% of the funding for  a Pharmacists and 100% of the cost of a Social Prescriber.  In future years the scheme will expand to include Paramedics, First point of contact MSK specialists, and Physicians Associates.

These posts must be additional and not simply substitute funding for existing posts.  So if CCGs or Practices currently employ people in these roles you cannot claim funding for your existing employees only for additional ones. The only exception is the national Pharmacists scheme where there was tapering funding.

So for example by 2024 a typical PCN of 50,000 might expect to employ 6 Pharmacists working across all the practices ranging from senior Pharmacists to newly qualified and potentially trainees and may included pharmacy technicians. 

The Pharmacists have shown that when working in practices they can help with workload both the provision of direct patient care but also in the area of prescribing and additional incentives will be available in terms of a new prescribing incentive scheme but based at Network level.

The Extended Access DES delivered at practice level, is currently worth about £88m nationally and this was going to end and there was the potential for this funding to be lost. It has been agreed that the funding for Extended Access will be transferred to the PCN who will become responsible for delivering this services with the same specification.  The PCN could agree to continue to provide the same service that it does now at practice level or develop a new service and collaborate across the PCN.

The Improving Access Fund which aims to provide better access but provided at scale is worth £6 per patient and was started with the Prime Minsters Challenge Fund and then gradually spread finally gaining national coverage in October 2018. To me it seems to duplicated the practice DES. Some CCGs contracted this service at scale from local practices or federations whereas some when to open procurement.

As part of the Partnership Review I saw practices who lost GPs who went to work in the newly established service following the commissioning of this service at scale. Concern over safe working limits and also capacity at the end of the day resulted in my recommendation which was that the £6/pt should go to PCNs and they should work with their practices and with the additional funding have the opportunity to provide those services and also add a degree of support and resilience to their practices.


5. What happens if we decide not to join the network?

Practices will not receive the funding or benefits detailed above and their patients might be put at a disadvantage.


Following the announcement of the GP contract for England, Krishna Kasaraneni, GPC England Executive member, has written a  blog  about what practices should be considering with regards to the structures for Primary Care Networks. This follows on from his previous blog  about PCNs.

Further guidance and information relating to GP contract will be published in the coming weeks.


3. Indemnity

This will be introduced in April 2019 and will cover all GPs and staff working in general practice. The introduction of this cover is an important factor not only in supporting practices today but protects GPs from potential increased costs in the future.

For partners there will an adjustment to the Global Sum to take into account the funding for Indemnity that sits within the expenses element of the Global Sum, but even after this is accounted for practices will see a 1.4% uplift in the Global Sum.

Locums will no longer need to pay indemnity when working for GP practices or networks. The cost of locums for practices should therefore be adjusted accordingly.

If you currently have Medical Indemnity through the MDU and you have moved to the new scheme whereby your premium has been reduced significant because you have moved from the 'Occurrence based cover to the claims based cover', you will need to purchase 'run off' cover to ensure that if a claim is made in the future that the costs of this will be met.  

Equally it is important that practices ensure all their staff have the cover that is required - so the LMC advice to practices is that if you have GPs who are covered by the MDU that you gain written confirmation that the appropriate run off cover has been obtained.

NHS Resolution will be managing any claims on behalf of the Government but you will still need some cover for any private work, seeking advice or representation at the GMC for example. This service will be similar to the cover that all Consultants have currently.


4. Staff Pay

The LMC has been asked by lots of practices about staff pay rises for this year following the publication of the contract.

Clearly that is for each practice to decide, but a 2% rise for all staff, including salaried GPs is what has been factored in to the global sum increases that practices can expect.


5. Access guidance

GPC England has released additional guidance that provides an overview of all elements of the contract agreement which could change how patients will access primary care in the future and the impact of these changes on practices.

You can read the access guidance here .


6. Pensions 

This is taken from the GPC/NHS England publication in relation to the new GP Contract.

'The annual allowance cap creates an incentive for GPs to either cut their time commitment to the NHS, or quit the NHS pension scheme altogether, thus leaving themselves and their families without coverage for ill-health retirement or death-in-service. This could be resolved by creating a new ‘partial pension’ option. Under this, GPs could choose to halve the rate at which their pension builds up, and in return pay half rate contributions. 

The Local Government Pension Scheme already has a 50% pension option and we have asked Government to consider this for GPs.

 In December 2018, the Department for Health and Social Care launched a consultation to increase the employer contribution rate from 14.3% to 20.6% from April 2019.

For this reason, alongside the five-year settlement for NHS England in June 2018, the Government committed to provide additional funding for the full costs arising from this actuarial revaluation for the NHS in England.General Practice will not have to bear any additional costs.'


Pensions blog

Here is the latest installment  of the Pension Blogs written by Dr Krishan Aggarwal - the lead for this area on the GPC.

The main focus of this blog is the Type 2 forms for Sessional GPs.


7. Cancer and primary care

There is clear improvements in cancer outcomes, which is great. Yet we still lag behind some Western Countries.

However, the numbers are going up and as GPs we may be seeing more patients either with symptoms suggestive of cancer or who have had cancer. There are some tools to help us identify patients earlier and gateway-C is one available to Dorset, Hampshire and IoW practices.

The National Cancer Diagnosis Audit 2019 is being launched 18th February, this follows the most recent audit that looked at 2014 data. Since then, 2015 NICE guidelines and pathways have been launched which should demonstrate even better improvements in patient outcomes. This audit looks at current patients from April 2019, which will be helpful to have more reflective discussions.

NHS England published a five-year framework for GP contract reform , on page 46 there is more guidance about cancer.

The LMC continues to work closely with the Wessex Cancer Network and also the local McMillan GPs.

Attached is the latest National Cancer Diagnostic Audit which practices should find helpful.


8. Recruitment for a GP with and interest in Perinatal Mental Health -

the LMC have been sent a potential job opportunity for a local GP to work with the NHS England Clinical Networks around perinatal mental health please see attached.


Best wishes


Dr Nigel Watson

Chief Executive

Wessex LMCs

Churchill House, 122-124 Hursley Rd

Chandler's Ford, Eastleigh

Hants. SO53 1JB (Registered Office)

Tel: 02380253874

Mobile: 07825173326


Attached file: NCDA A4_GP_v5_handout.pdf

Attached file: RCGP Perinatal Mental Health GP Champion Project Advert.pdf

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Updated on Friday, 22 February 2019 1061 views