PCNs in crisis as GP leaders call on profession to reject network DES

The future of primary care networks (PCNs) has been left in major doubt after LMCs voted for the profession to reject the network DES in its current form.

GP leaders at a special conference of England LMCs in London voted in favour of a motion condemning the network DES - which underpins GP practices' involvement in PCNs - as a 'Trojan Horse to transfer work from secondary to primary care'.

The motion backed by LMCs calls for 'immediate cessation' of the transfer of responsibility for enhanced services from practices to PCNs, and demands an urgent survey of the profession to find out whether practices plan to sign up to the network DES.

It called on the BMA's GP committee to negotiate extra funding for core general practice - warning that trusting partners with 'realistic investment' was the 'only way to resolve the crisis in general practice'.

Ahead of the conference, the GPC said that the contract for this year, including the network contract DES, had been agreed and was not up for renegotiation. However the strength of feeling in the debate suggests that many practices may not be willing to sign up to the DES again this year. A poll by GPonline earlier this week suggested that a third of practices could decide not to take part in the network contract DES in the coming year.

GP workload

Proposing the motion, Berkshire LMC's Dr Simon Ruffle reminded the BMA of a line spoken by one of its negotiators at last year's annual conference. Speaking about the five-year contract deal, the negotiator said:  'You asked, we delivered.'

But Dr Ruffle said: 'We asked for free range corn-fed chicken. What we got was washed in chlorine and shaped into nuggets.' He said the network DES had not made general practice more able to deliver core services, but had instead added to workload.

BMA GP committee chair Dr Richard Vautrey urged LMCs not to support the motion, but delegates backed it in all parts.

The crucial vote plunging the future of PCNs into doubt came at the end of a day in which a string of debates saw LMC leaders at the conference express huge reservations about the introduction of PCNs, less than a year after their launch.

GPs raised concerns about the lack of funding, workload involved, the availability of staff to fill new roles and highlighted fears that practices' long-term financial survival could end up dependent on their involvement in networks, effectively making participation mandatory.

Primary care networks

The conference backed a motion that called for the deadline for practices to sign up network contract DES for 2020/21 to be deferred until 1 October 2020. At the moment practices are expected to sign up to the DES by 31 May, but it remains unclear whether the GPC would have any leeway to renegotiate this particular aspect of the contract deal.

Delegates highlighted a number of issues with the enhanced health in care home service specification that networks will be required to deliver later this year. They argued that the £120 payment per bed was insufficient for the work involved and instructed the GPC to negotiate an increase in funding for 2021/22 and that payment should be per patient rather than per bed.

They also voted for the GPC to ensure that the priority area for investment in future years of the contract was the core contract, rather than PCNs and that any changes to the network contract DES must not have a negative impact on core funding.

Delegates hit out at the GPC for failing to provide any financial modelling on how participation in the network contract DES would impact on practices' finances. They also said that the information available to PCNs about tax, VAT and PAYE had been 'confusing and inadequate' and had 'placed practices at risk'.

Tax warning

GPs backed a motion calling for NHS England to fund tax advice to PCNs and demanded that the BMA explained what discussions it had undertaken with HMRC about the tax implications of networks before agreeing to the network contract DES.

GPC executive member Dr Krishna Kasaraneni said that the GPC had used a real PCN to undertake financial modelling. However, GPC member Dr Michelle Drage said that she had not seen any modelling, despite asking for this. She added that the BMA's online 'ready reckoner' only showed income and didn't take account of expenses.

During a debate on additional staff that will to be employed by PCNs over the next five years, delegates highlighed a lack of funding for training, the lack of available staff to recruit, lack of space in premises, and fears that the staff they could recruit would do little to reduce current practice workload as their key concerns.

Currently, if PCNs fail to spend money allocated to them under the additional roles reimnbursement scheme (ARRS), this funding is lost to them and goes back in a pot to potentially be shared among other PCNs who can recruit. However the conference backed a motion that called for any unspent funding to remain in the network, regardless of whether or not they could recruit.

Dr Nick Mann from Hackney and City LMC said PCNs were an 'iceberg' and 90% of their impact was 'unknown'.

'It's entirely new work that may or may not be funded or staffable,' he said. 'At least four additional workstreams and pay for performance metrics. It's a massive hoop-jumping exercise with lots of strings - and potentially a pathway to managed care.'

Dr Francesca Frame from Cambridgeshire LMC said she did not have adequate information to make an informed decision about the impact of signing up to the DES.

'I would not expect a patient to make an informed decision about their health without the necessary information,' she said. 'Why should I accept less when considering a contract that could threaten the stability of my practice. We need more time to make an informed decision about this DES.'

Read the motion in full:

AGENDA COMMITTEE TO BE PROPOSED BY BERKSHIRE: That conference believes the PCN DES is a Trojan horse to transfer work from secondary care to primary care and that:

(i) this strategy poses an existential threat to the independent contractor model

(ii) there should be immediate cessation of LES and DES transfers from practice responsibility to that of PCNs

(iii) GPC England is mandated to urgently survey the profession to get feedback on whether they intend to sign the new PCN DES

(iv) GPC England must urgently negotiate investment directly into the core contract as the only way to resolve the crisis in general practice is by trusting GP partners with realistic investment

(v) the profession should reject the PCN DES as currently written

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