PCNs

Primary care networks (PCNs) form a key building block of the NHS Long Term Plan.

As discussed in previous articles, PCNs will consist of a grouping of GP practices within a geographical area, typically covering a population of 30,000 - 50,000 patients. Bringing general practices together to work at scale in this way is intended to tackle a number of issues, including improving the ability for practices to recruit and retain staff; to allow for practices to better manage a growing, and increasingly complex workload; and to meet the needs of patients better.

PCN DES

The PCN DES, also known as the Primary Care Network Contract, allows for practices to develop and implement PCNs, working with neighbouring practices to share resource and skillset.

The DES provides for workforce reimbursement for a PCN on a 70/30 split. The reimbursement covers a number of specified health professionals, and is designed to allow PCNs to build up an expanded primary care team. Provided PCNs are established by 1 July 2019, funding towards the additional workforce will then run until 2024.

Workforce expansion

The purpose of PCNs is to expand the workforce team beyond the current numbers. This is crucial, to tackle the major issue of understaffing and resource, and the difficulties faced in general practice to recruit and retain GPs. The idea of PCNs is therefore not about substituting GPs, nurses and the other staff required to run general practice on a day-to-day basis, but to take some work off them and share the workload with new positions, to make the whole system more manageable and sustainable.

Going forward, it is therefore anticipated that each practice will have a clinical pharmacist(s), physiotherapy practitioner(s), physician associate(s), paramedic(s) and social prescriber(s). Each PCN will have its own clinical director, and this role will be undertaken by a GP – the idea being that clinicians in leadership roles means there is better opportunity for the system to work for practices, patients, and of course, the workforce.

Practical workforce considerations

Just what impact PCNs will have on issues such as recruitment and retention, and, in turn, addressing the ever-increasing workload in GP practices, is yet to be seen – only time will tell. PCNs are, however, an initiative created in recognition that while there is extreme under resource in general practice, the ability to simply ‘add’ the necessary volume of GPs to the ‘pot’ is not that easy to achieve.

And so we turn to workforce issues that a practice needs to consider when entering into a PCN; both before entering into a PCN, once in a PCN, and at the end of the five year funding arrangement and/or when leaving a PCN:

Before entering into a PCN

The PCN structure needs to be decided upon

There are pros and cons to the various PCN structures, and no structure is ‘perfect’, but below are some of the issues to consider:

Flat practice structure (shared/joint employment)

Employment of staff under shared employment contracts so employment liabilities are shared between all the practices.

Liability would not be limited under this arrangement so the practices need to consider their exposure to this.

Shared employment contracts - so no supply of staff, and therefore no VAT issues.

Staff would be able to join the NHS pension scheme, as the practices would hold an NHS contract.

One practice would be the nominated payee and receive the DES funding, run the payroll and pay the staff. A separate bank account would need to be opened.

To manage staff operationally, on a day-to-day basis, there should be a nominated line manager(s), and HR policies and procedures.

Lead practice structure

If other practices in the PCN pay for staff, and/or staff were ‘seconded’ to work in the other practices, there would be potential VAT issues.

Staff would be able to join the NHS pension scheme, as the (lead) practice(s) would hold an NHS contract.

The lead practice would receive the DES funding, and be the nominated payee for workforce costs etc.

The lead practice may be nominated to manage the workforce, use its policies and procedures etc.
Separate limited company

Alternatively, if there were shared employment contracts between the practices and the PCN Co, employment liabilities are shared

If shared employment contracts were in place between the PCN Co and all the practices, there would be no supply of staff, so VAT would not be an issue. But, then there could be liability issues (see employment column).

As the company is not an employing authority, staff employed would not have access to the NHS pension scheme.

The DES funding would need to be paid to a nominated practice, as the company cannot receive the DES funding, as it does not hold a PMS contract.

Also, a limited company is a separate entity and would have shareholders. Each practice would need to nominate a partner to be the shareholder as a practice cannot hold shares themselves.

Network Agreements will need preparing, and will include a workforce schedule which covers, among other things, how to manage the employment of network employees, liabilities and indemnities.

Contractual documentation will need preparing for the PCN workforce. Just how this is prepared will depend on the PCN structure adopted. The clinical director post will need contractual documentation in place, and this may be in the form of a consultancy agreement, or a fixed-term contract of employment. As the clinical director will continue with their clinical role, it is likely they will need to drop sessions, and so agreements will need to be reached in this regard, including what happens if/when the clinical director role comes to an end.

Once in a PCN

For a PCN to be successful it will be essential to concentrate on the desired cultural identity and how this can be put into practice, through decision-making, policy and procedure.

Recruitment of the workforce

In line with the overall purpose of the PCNs, the practices will need to build their workforce, and look to recruit clinical pharmacist(s), physiotherapy practitioner(s), physician associate(s), paramedic(s) and social prescriber(s). The clinical director also needs appointing, if not already in place. Just how recruitment takes place will need agreeing between the practices – is this a collective responsibility, a role assigned to a few key individuals, or to a nominated practice?

Leadership, culture and integration

The leadership structure and strategy will need developing, to ensure the right culture is created, and filtered through the PCN. How will key decisions be reached - voting with unanimous agreement, or a simple majority? There also needs to be a strategy and workforce plan for collaboration and integration.

Policies and procedures

Practices will need to decide whether they will keep their own policies and procedures, or create and adopt unified policies and procedures. If it is the latter, there will need to be sufficient consultation. Even if each practice decides they want to keep their own policies and procedures for their ‘existing’ staff, there will be the issue of what to do in relation to the ‘PCN workforce’. The risk of different policies and procedures for different staff is general confusion and difficulty managing, creating a two-tiered workforce, and/or unfairness and inconsistencies (potentially even discrimination).

Line management needs addressing. Clear lines of responsibility and management need establishing, so that effective day-to-day management, appraisals, performance management, disciplinaries, grievances etc. can take place. Communication and engagement with staff is then crucial.

Recruitment and retention

Initiatives need implementing to make the practices/PCN attractive, to encourage recruitment and support retention. This is wider than just remuneration, but includes training, and development.

At the end of the five year funding and/or when leaving a PCN

Redundancies, restructuring and suitable alternative employment

If the PCN DES is removed at the end of the five years, practices may need to consider redundancies and/or restructuring. Consultation (possibly even collective consultation) would need to take place with those at risk, and alternatives to redundancy considered and implemented where possible.

Varying contract terms

Contracts of employment and/or contractual documentation may need amending to reflect changes in the PCN. Contractual terms can only be varied in accordance with any variation provisions in the contract itself, or by the agreement of the parties.

Conclusion

PCNs are a new and developing area. There is much debate over PCNs and how the new workforce expansion will support GPs and practices; only time will tell. This article intends to simply highlight some of the workforce issues that will require consideration by practices/PCNs. Please do contact us for further information or advice.