Primary Care Networks– Creation and Implementation
The latest version of the NHSE Operating Plan provides for CCGs to actively encourage every practice in England to be part of a local primary care network so that these cover the whole country as far as possible by the end of 2018/19. Primary care networks (‘PCN’) will be based on GP registered lists, typically serving natural communities of around 30,000 to 50,000. They should be small enough to provide the personal care valued by both patients and GPs, but large enough to have impact and economies of scale through better collaboration between practices and others in the local health and social care system.
NHS England has said individual GP practices “will enter into a network contract, as an extension of their current contract”. The network contracts will have a “designated fund” and will be part of the new multi-year GP contract agreement currently being negotiated between NHS England and the British Medical Association. According to the long-term plan, enhanced service contracts commissioned by clinical commissioning groups will also be added to the new network contract.
While it is easy for a strategic plan to say that something will happen, it is a very different matter for practices within a locality to work out how they will work together to create a PCN and how the ‘network contract’ will apply and what conditions might be attached.
The team will advise on how best to form a PCN locally and will advise on the engagement work that needs to be done as a first step, the legal implications of a ‘network contract’, any legal agreements that would need to be in place for practices to meet the requirements of the contract (including the mandated Network Agreement) and the governance arrangements that will need to be in place as a result. We will provide regular updates as NHSE guidance becomes clearer using our contact base so the PCN is fully up-to-speed with latest developments.
Super Partnerships – Creation and Implementation
The Our Health Partnership in Birmingham is one of the premier examples of a ‘Super Partnership’ which is a possible solution for GPs wishing to work at scale but to protect the partnership model. The team advised on the creation, legal implementation, governance aspects and financial consequences for partners and staff.
OHP now numbers some 37 practices, 189 GP partners and circa 70 salaried GPs serving around 300,000 patients in Birmingham, Sutton Coldfield, Wolverhampton, Solihull and Shropshire. The partnership offers a shared administrative and management structure, cutting down the time doctors have to spend on admin. It opens up economies of scale to get best value from budgets. It has the resources to develop innovative services and effective partnerships with local hospitals and care services. And it can access new funding streams that are only available to large GP organisations.
The team will work with interested partners to do the preparatory work to create the right conditions for the adoption of a super partnership model (including versions other than the OHP model) and will advise on the correct legal structures for implementation. The team will also advise on governance and how best to embed this to allow the new organisation to function as efficiently as possible. The team will advise on the financial consequences for partners and what they must be aware of before embarking on the model.
Legal drafting and accounting advice are services that would need to be provided separately and the choice of provider can either be left to GP partners or the team can bring in their preferred suppliers to act for the GP partners independently.
Other Legal Structures
This may be the moment for GPs to consider other acceptable legal forms to govern their collaboration in PCNs. The partnership model is not the only permitted legal structure to hold GMS (and both PMS and APMS) contracts. Indeed others may well be much more efficient from a tax viewpoint and will provide cover from the unlimited liability issue that current partnerships face.
The team has a great deal of experience of formation of different legal forms (companies limited by shares, by guarantee or community interest companies for example) and will provide advice on formation and will provide legal documents if required and undertake the practical formation if needs be. This would include an examination of the most efficient structure from a tax position.
Business Expansion and Efficiency
There will be a number of opportunities for PCNs to ensure individual partnerships boost their profitability as closer working practices are established. PCNs could also consider adopting well-established frameworks to use a triage system to separate urgent and non-urgent appointments and empirical data shows that this actually allows a practice to keep the daily urgent list open longer and makes use of the wider clinical workforce to offer more appointments that are tailored to patient needs. Over time, PCNs may well be able to take on larger services, either individually or in ‘clusters’, which will see more out of hospital work under the control of GPs.
We have the capacity and knowledge-base to advise on a range of business efficiency solutions, from cashflow analysis through to implementation of appointment triage. We also have wide experience in bidding for services and can advise through direct award up to full ITT. We seek to work with GPs as they decide on the pace at which they want to adopt new services and working practices and provide tailored advice for the circumstances.
‘Vertical Integration’ and dealing with NHS Trusts
In various parts of the country NHS Trusts are using an integration model (which is termed Vertical Integration by the Royal Wolverhampton NHS Trust) to provide a solution to sustainability for GPs who might be experiencing difficulty or who are looking for a solution to ‘last man standing’ issues.
The model is operated by both Foundation Trusts (Northumbria, Royal Devon & Exeter) and NHS Trusts (Royal Wolverhampton) and has a number of attractions. However GPs considering this route (which is likely to be used increasingly frequently to solve a pressing problem) need to be advised in detail about the implications and to ensure they obtain the correct benefit from any such process.
The team will advise on the strategy that a partnership should use when dealing with a Trust in these circumstances and will provide detailed advice on the legal implications and any legal documents that need to be completed to effect the integration. The team will also ensure that the partners obtain the correct financial benefit for the transaction, including any subsequent employment issues for partners or their staff.
PCNs may also need to deal with other NHS organisations in collaboration to form an Integrated Care Provider (‘ICP’) solution. This will likely be governed by a new form of contract (NHSE has released the draft version of an ICP Contract). We will provide advice to PCNs on how to position themselves in such a situation and will further advise on the contractual arrangements to ensure the PCN is ideally positioned.
Advice on property development and access to capital for PCN sites
Now that PCNs are the accepted ‘direction of travel’ there may be opportunities for GPs to invest in new buildings and thereby ensure they have a capital interest in their future development. The limitation of the prohibition on transfer of goodwill on transfer of a GMS means that the only ‘business investment’ GPs can do is through property. PCNs could provide an impetus for a new phase of property development to create new purpose-built PCN centres. This may well be an attractive opportunity for a new generation of GP partners.
There is also the issue of what to do with existing practice properties as PCNs coalesce and it is quite possible that certain practice premises will be surplus to requirement. GP may want advice on how best to dispose of these properties. Tanza Partners can offer detailed development advice through its associates and in addition has access to pools of private capital that are interested in funding development sites specifically in General Practice. Tanza can offer a fully tailored solution that will cover all aspects of any proposed property transaction.