Part two: Primary Care Networks - key points for general practice
Details
Further to part one which sets out the key points regarding Network DES implementation, part two explores some of the potential network models available that can be tailored to meet different needs.
Options for collaboration
There is no one delivery model for a network that is the right fit for all, as we have seen to date from the move to at-scale working.
Model 1 – Unincorporated practice network (shared employment model)
| Model 1 – Unincorporated practice network (shared employment model) | |
|---|---|
| NHS pension | None anticipated |
| Subcontracting issues | None anticipated |
| Employment issues | Joint employment arrangements must be agreed between the network practices |
| VAT issues | None anticipated |
| CQC issues | None anticipated |
| Network Agreement | May be difficult to agree Network Agreement as between the network practices |
| Liabilities/risk sharing | May be difficult to agree risk share split as between the network practices |
Model 2 – Unincorporated lead practice network (hosted employment model)
| Model 2 – Unincorporated lead practice network (hosted employment model) | |
|---|---|
| NHS pension | None anticipated |
| Subcontracting issues | Subcontracting is likely to be required as between the network practices |
| Employment issues | The lead practice will employ all staff and thus assumes liabilities |
| VAT issues | There may be VAT issues if staff are not seen to be providing VAT-exempt healthcare services |
| CQC issues | None anticipated |
| Network Agreement | May be difficult to agree Network Agreement as between the network practices |
| Liabilities/risk sharing | The lead practice will be primarily liable – it may be difficult to agree risk share split as between the network practices. If the lead practice is not a limited liability entity (i.e. it is a single-hander GP or partnership), its liability will be unlimited |
Model 3 – Incorporated primary care network (non-contract-holding model)
| Model 3 – Incorporated primary care network (Non-contract-holding model) | |
|---|---|
| NHS pension | The incorporated entity will need to put in place a qualifying subcontract for the DES services in order to secure the NHS Pension. Discussions with NHS England are ongoing |
| Subcontracting issues | Relevant regulations must be considered when subcontracting |
| Employment issues | None anticipated, liabilities limited due to legal nature of vehicle |
| VAT issues | There may be VAT issues if staff are not seen to be providing VAT-exempt healthcare services |
| CQC issues | Potential CQC issues depending upon who is delivering regulated activity |
| Network Agreement | Potential advantages in agreeing the network agreement between practices, as vehicle governance and processes can be mirrored at network level if the vehicle is already in existence |
| Liabilities/risk sharing | Limited liability due to legal nature of vehicle |
Model 4 – Incorporated primary care network (contract-holding model)
| Model 4 – Incorporated primary care network (Contract-holding model) | |
|---|---|
| NHS pension | None anticipated, providing vehicle has access to NHS pension |
| Subcontracting issues | Relevant regulations must be considered when subcontracting |
| Employment issues | None anticipated, liabilities limited due to legal nature of vehicle |
| VAT issues | There may be VAT issues if staff are not seen to be providing VAT-exempt healthcare services |
| CQC issues | None anticipated |
| Network Agreement | Potential advantages in agreeing the network agreement between practices as vehicle governance and processes can be mirrored at network level if the vehicle is already in existence |
| Liabilities/risk sharing | Limited liability due to legal nature of vehicle |
Model 5 – Single provider network (generally in excess of 50,000 patients)
| Model 5 – Single provider network (Generally in excess of 50,000 patients) | |
|---|---|
| NHS pension | None anticipated |
| Subcontracting issues | Relevant regulations must be considered when subcontracting |
| Employment issues | None anticipated, however liabilities would exist for the super-practice unless it is incorporated as a limited liability vehicle |
| VAT issues | None anticipated |
| CQC issues | None anticipated |
| Network Agreement | Potential advantages in agreeing the network agreement between practices as super-practice governance and processes can be mirrored at network level |
| Liabilities/risk sharing | Limited liability if the super-practice is incorporated |
Model 6 – Non-GP employer host
| Model 6 – Non-GP employer host | |
|---|---|
| NHS pension | None anticipated |
| Subcontracting issues | Relevant regulations must be considered when subcontracting |
| Employment issues | None anticipated as staff are employed by the non-GP employer |
| VAT issues | There may be VAT issues if staff are not seen to be providing VAT-exempt healthcare services |
| CQC issues | None anticipated |
| Network Agreement | May be difficult to agree Network Agreement as between the network practices; involvement of the non-GP employer will also be required, which may result in control being relinquished at GP level |
| Liabilities/risk sharing | Some risk taken on by non-GP employer; may be difficult to agree other risk share split as between the network practices |
Developing your network
Potential key issues to be considered:
- Host organisations: Does your federation hold a GMS/PMS/APMS contract? Is it willing to act as the host organisation for your network? Could your host also hold the employment contracts for additional staff? Will this affect eligibility for the NHS Pension?
- Employment: Will employment liabilities be subsumed by the host organisation or shared among network members? Who will be responsible for day-to-day management of the additional staff? Who will be responsible for the additional staff once funding ends?
- Network clinical director: Will the role be filled by appointment or election? Do you already have a suitable individual in place with capacity to take on the clinical director role? Do you have processes in place that you can replicate for the recruitment process?
- Governance: How will you make decisions as a network, e.g. on spend and service delivery? Do you already collaborate through a corporate model? Can its corporate governance be mirrored at network level or inform network governance? Can this be replicated for networks across your federation area? Do you operate under a MoU or alliance contract? Can its governance be mirrored at network level or inform network governance?
- Risk sharing: Do you need a risk/gain share mechanism in your Network Agreement? If so, will this be an even split or shared between practices based upon their list size? How will you share the risk of the employment?
Our primary care lawyers offer practical and proactive advice to give you robust solutions to further your business and enable you to deliver improved outcomes for your patients. Our specialists have worked with primary care at scale for many years and we know the models that work and the behaviours that will enable effective collaboration. Our dedicated primary care team has put together a flexible ‘menu’ of legal assistance, which we can deliver on time and on budget.
