Justin 00:00:16.160

Welcome. Thank you for coming on to the Hempsons podcast. This is a series of Primary Care podcasts that we have and today you have got Justin Cumberlege and I am a partner in our London commercial team, and Robert McCartney. And we're going to be talking about preparing your PCN for 2024 and beyond. So I'm just going to hand you over to Robert.

Robert 00:00:43.760

Thanks, Justin. So, yes, my name is Robert McCartney. I'm relatively new at Hempsons and joined a short while ago, but have been working in primary care for many years now with a combination of in house and in practice support. So I've got a very practical view on how to apply some of this, some of the changes.

Justin 00:01:05.720

So you're going to have a bit of a conversation between Robert and I about what we think the future lies for PCNs. Robert, they've been around now since 2019. What do you feel PCNs have achieved in that time?

Robert 00:01:24.080

An awful lot, to be honest. I think people can step back and really look at a huge amount of change. Yes, some PCNs are still struggling and still in the early days, but if you look at those who have really developed and taken the opportunities that are available to maximise the revenue, they've made some massive changes to the way they're delivering services, the way they're helping their practices, and the way they're securing money for their practices.

Justin 00:01:55.490

Absolutely. Some PCNS or practises have really upped their game, haven't they? And it was such a shock when it came in in 2019. I mean, there was so little preparation, and no one knew about data sharing, and there were a whole lot of unknowns. And yet, particularly with COVID, it was almost as if someone had been thinking about a pandemic coming along when they formed PCNs in a hurry, because some of them really came into their own during that period.

Robert 00:02:30.420

That is a particularly interesting example of how you don't realise that you're preparing for something when you actually are. When they were first announced in early 2019, I don't think anybody was really prepared for them - even if you were some of the pilot sites, some of the sites that were being used by the NAPC, they didn't really understand exactly what was going to be announced by the government. And the fact that they've been able to develop so quickly in that time is a really huge testament to the people out there actually working on the PCNs.

Justin 00:03:11.700

Absolutely. And having the day job as it were, at the same time. And then we've had all these additional staff that have come in. So to begin with, we just had the pharmacists and the social prescribers, which was quite a sort of easy one. But now some PCNs have got quite a large staff, they’ve got about 30 odd people sometimes. It's a huge liability for practices. We're often asked about incorporation of PCNs. What do you think about that?

Robert 00:03:48.780

The staffing is one of the key areas to motivate or to push incorporation. There's no doubt that these are large organisations. If you were to set up a business from scratch and say well, within a few years you're going to have a multimillion-pound turnover of a workforce of 50 plus in some situations, that would be quite remarkable to do in the time frame, especially if you then put in the context of a national pandemic and disaster.

Now, with the incorporation question, I think this is where people are now saying are we actually structured to be able to be ready for the next stage? Or, the initial reactionary stage has passed and now what is the long term kind of plan and how do we actually implement it?

Justin 00:04:41.700

I think many don't really understand some of the advantages of a company. I mean, it's not something that I push onto anybody as a PCN, “should we form a company?”. I mean, one of the things to remember is that in fact the PCN cannot incorporate and that you remain the contractor as individual practices, working together in this sort of rather odd way that the PCN network contract has been put together.

But I think what you're doing is creating this service company. And companies ever since 1860s, when they first sort of came about, the whole concept about it is limited liability. So that is a good thing, especially if you're employing a lot of staff and dealing with a higher level, perhaps, of uncertainty and risk than you're used to as a practice. Not having your own house on the line is perhaps a comfort and makes it easier to sleep at night, although there are some complications that come with that, aren't there? When you create that company?

Robert 00:05:55.480

The formation process itself requires a number of hurdles to be jumped through. There's various regulatory requirements that have to be satisfied; depending on whether or not you want to be a provider company determines whether or not you also need CQC registration and all the fun and games that come with once you're registered, actually maintaining the registration. There's a huge amount of management and responsibility, particularly on the directors. And one of the things I think we frequently have a discussion about with our clients is understanding that if you're stepping into the role as a director, you are acting for that company. So you have to be able to take that hat off from the partnership and put the director hat on for the company. And that's quite a big transition and it's certainly one which I think kind of mirrors the entire requirement for working at a PCN, because the PCN concept as a whole is you're working together for a neighbourhood, for a locality, and not just for your partnership.

Justin 00:07:05.990

Yeah, it is a slight mindset shift, isn't it? And directors do have statutory responsibilities. Sections 171 to 179 set those out clearly and you need to be mindful of those. Having said that, one could sort of make the things sound much more frightening than it really is. Because if you're properly advised and you're not acting fraudulently or anything like that, there are lots and lots of company directors over the country who have never run into any sort of trouble at all. And there's no reason why a PCN company director should either. And it is a useful vehicle just to be that legal entity. And maybe looking at the future, it might have an advantage then as well.

Robert 00:08:08.510

Well, one of the recurring themes that we've discussed is the concept of trust, and importantly the trust from commissioners to providers. Moving forward, it looks increasingly like the concept of PCN and very much the concept of neighbourhood working is going to be the future of where services are going to be delivered. So, on that basis we ask the question, will the commissioners trust you to be able to manage that budget, manage the work and manage the outcomes that they're looking for in your area?. And a vehicle which is properly registered, well run and has the experience of pulling together from the practices is something that will give greater confidence for many in the commissioning world.

Justin 00:09:02.110

Absolutely. And going back to the Companies Act, you have got a structure there ready made. It's a very flexible structure, which is one of the beauties about companies. But the fact that you've got that structure in place with your directors on the one hand and your shareholders on the other hand who don't have to be the same people. So you can have that check and balance and you can hardwire in that company into your network as well as a member of the network and your network agreement reflecting the fact that you've got the company. And if you mirror the company structure in your network agreement, you can avoid a lot of duplication. So, the board of the network is the same as the board of a company, for example. And also, of course, you can open up a bank account as a company, so you can sort of get a bit more transparency over the finances, especially when they changed the rules so that the money can go straight into a nominated bank account, which is not the bank account of an individual practice.

Robert 00:10:12.440

I think for many areas, that was a bit of a game changer, as it allowed PCNs to actually take full control of the account rather than have to piggyback off an individual practice. And that's one of those areas where I've seen a lot of people going, actually, now that we've freed up the money and put them into an account, how do we manage it, have the right governance structures around it to give assurances to everybody?

Justin 00:10:38.040

Yeah, absolutely. Having that company, I think in the future, when you're looking at the commissioners, they're going to say, well, who am I going to be contracting to? And they're not going to be really thrilled at the thought that they're going to be contracted with essentially a whole lot of partners who cover a population of, say, 30 to 50,000. They're going to be more interested in saying, actually, we're going to contract with that single entity. And that single entity might not even be PCN size, it might be the size of what they say at place. So you're talking about a population of 250 to 500, even a million. And that, of course, goes back to the days of federations.

Robert 00:11:29.850

It does, it cyclical in that way. I think the difference is that if they commission, and I think we're seeing examples of this - if they commission at that place level, the question is, how is delivery going to actually occur? And that's where we get back down to the neighbourhood level, the practices working together with PCNs, and that changes the role of the PCN slightly, because it becomes this delivery entity. There's always been a bit of lack of clarity shall we say, as to whether or not the role of the PCN was as a provider or as a kind of quasi commissioner at a local level. And I think we're seeing slightly less involvement of that, the commissioner part, but definitely a growth in the provider role. I don't know if that might change in the future with levels of engagement, particularly being driven by bringing on the integrated Neighbourhood team approach. That might shift, but certainly for the foreseeable future, provision is increasingly going to be at scale, but at PCN level, linked to the practices.

Justin 00:12:45.850

Yeah, I agree. I can see that you need a primary care organisation which is covering the same population as the District General Hospital, for example, and that organisation, let's call it the GP Federation, but it could be something else would then, as you sort of said, subcommission. I mean, in legal terms, subcontract, but subcommission the provision of that service by down at the neighbourhood level, and that's where your PCNs come in. And they may even subcommission, if you like, to practice level depending on the ways that the relationships work.

Robert 00:13:27.490

Time for me to ask you a question then. Here's one that we've been thinking about… what about the role of super practices and large mergers in any given area? Now, is it worth them also considering incorporation or have they got sufficient structure that they won't necessarily need to?

Justin 00:13:48.760

It depends very much on what that super practice wants to do and how it wants to evolve. I mean, some of them have become PCNs in themselves because they're geographically centred and for them to incorporate seems to make quite a lot of sense because they'll be an incorporated PCN and quite a powerful unit. Where they've got practices which are in different PCNs, it becomes a bit more complicated as far as funding is concerned and so on, and they might want to continue to be structured as partnerships as opposed to being a corporate body which is then in various different PCNs. There's also an issue that we come across where if you've got an incorporated practice in an area which has got a GP Federation that then wants to take on a GMS contract, the regulations don't allow that incorporated company to be a shareholder in the GP Federation to hold a GMs contract. I mean, that is a quirk of the regulations, but I'm afraid that's where we are until perhaps they change the nature of primary care contracts.

It's worth mentioning at this moment that of course the Health and Social Care Act allows for the creation of primary care trusts. Now, not to be confused with PCTs that we had under the 2012 act, prior to the 2012 act, but those primary care trusts could be NHS trusts which are carrying out what you might call GP services. So see that as a challenge perhaps or a threat to your area, I don't know. But just being aware that there is that prospect of a legal entity and that sort of circulates around the argument of GPS being employed by the NHS.

Robert 00:16:01.930

It comes back to that discussion about first called horizontal integration which has been going on feels like forever, to be honest. But there is certainly a vehicle for it. I think everybody saw in the media not too long ago there seemed to be some political support for particular models and then those models themselves have had problems subsequently. But it does raise various questions about, as an entity at a PCN level, the level of engagement that you're seeking from your community providers, your acute providers, your mental health providers. It is difficult for them. They don't have the resources, that's been a recurring theme. They don't have the resources to work with every single PCN at the level of strategic and service redesign that would be preferable. And that pushes it back to the argument that there needs to be some sort of place-based structure that can then filter down into PCNs and then into the practices.

Justin 00:17:13.610

So I think that future PCNs is bright. It's very important that they are well structured, well run, have good, what we call corporate governance and financial governance and clinical governance surrounding them, that there's a decision making process which avoids disputes or resolves disputes as quickly and amicably as possible, and that they have the confidence to take on the contracts for their population and deliver those well.

Robert 00:17:52.550

Yeah, very much so. I think the key question really is whether or not PCNs will continue with that branding. I think there might be a shift towards neighbourhood teams or something similar, but at its very heart, collaborative working amongst practices in a defined geographical area is not going anywhere. And if you are minded to formalise that in the form of an incorporation or some other entity, then I think you'd be in a very strong position to have the kind of building blocks for what will come in the future, even if maybe the names might need to change slightly.

Justin 00:18:39.070

Yeah, absolutely. And then also you've got an entity which can go to say, the council, social services team, mental health teams and so on, and say, look, you need to collaborate with us, this entity, and partly the importance of keeping GP services at the heart of health and social care because it's GPS in the end who know the individuals and the families that need help and support to live long and healthy lives.

Robert 00:19:14.660

And I guess to build on that… We've talked about a lot about how PCNs will fit in the new system, but actually at their heart they have an essential role with their community and supporting their practices. When the concept was first announced in 2019, there was a lot of discussion about well, how do these help practices? I think it's fair to say it's been variable and mixed results on that front but, as they've developed further and more kind of integrated working, shared teams, shared ways of delivering services, and shared ways of delivering support to your communities, as they've evolved and they've developed, they've really helped practices to secure kind of their position. There's still a long way to go, though.

Justin 00:20:07.810

Absolutely. And people develop at different paces. Thank you, Robert. It's been really interesting discussing about this today and I hope those of you who have listened to this podcast have enjoyed it. Do contact us or any of our team in Newcastle, Harrogate, Manchester, London or Southampton and we would be absolutely delighted to hear from you and to help you prepare for the changes which are no doubt coming about. Thank you.