Opinion: An imposition – thoughts on the PCN DES

The much awaited, or much feared, PCN DES is out and there are no surprises. With no negotiations done with the BMA General Practitioners Committee (GPC), it has the feel of an imposed and ill-considered contract.

Most of the previous targets have been increased. The additional roles reimbursement scheme (ARRS), along with the DES is still very restrictive and micromanaged.

I won’t discuss every indicator, but let’s look at some interesting ones. Faecal immunochemical testing (FIT) for colorectal pathways has been a topic of discussion in our area for a while, and is now coming through the investment and impact fund (IIF). Why? Because although NHS England and politicians want us to refer more patients with potential cancer, they have not commissioned enough capacity in secondary care. Naturally the brunt of this is borne by GPs. Although the NICE guidance is not being updated, there will be a push to do FIT tests even for barn-door referrals. Previously, I asked the CCG to get hospitals to send FIT tests out and do their own triage for referrals, but they want us to do it. But there is the potential for missed cancers and the whole medicolegal risk will sit with us. We should push for secondary care to do this as part of their triage process, not ours.

With regard to the switching of patients to edoxaban – no evidence has been provided by NHS England for why we should do this. If the reason is cost, it should be stated in black and white. GPs are not averse to having difficult conversations with patients, but we would appreciate evidence or support to facilitate them. The lack of evidence creates an ethical dilemma for clinicians.

Our PCN’s practices have decided to put ethics and patient safety first and we will not actively pursue those two IIF targets. If we hit them, we hit them, but not at the expense of patient care, our workload and wellbeing.

Then there is enhanced access. Confusion reigns. We wondered, do we need a GP present all the time? The contract mentions supervision could be remote. The GPC asked for clarification, and NHS England said yes, we need a GP at all times – as reported by Pulse. The way things are going we will need to have GP cover throughout our core hours from 8am to 6.30pm, then during the enhanced access hours of 6.30pm to 8pm and on Saturdays. I wouldn’t be surprised if these hours move into our core GMS contract and we end up providing seven-day cover, maybe even for 24 hours.

But I am hoping practices and CCGs will be more reasonable when deciding what is best for their local needs. I suggest all PCNs do the same, and seek LMC support where they need it. Certainly in our area we understand it to mean that a GP must be available on call or via remote appointments but not necessarily physically ever-present. Practices did not even have clarity until before the 30 April opt-out from the PCN DES. To protect their dwindling incomes and because no alternative has been offered by our leaders, most
have signed up. This will be sold as a huge success by NHS England.

However, with significant funding going into IIF, the only positive of the DES is that practices will have the luxury of choosing what is deliverable rather than burning out to achieve everything.

Dr Manu Agrawal is clinical director of Cannock North PCN, Staffordshire, and chair of South Staffordshire LMC