Why attending less meetings will increase the influence of your PCN

It will come as no shock when I tell you that the NHS has a meetings culture.  The NHS loves meetings.  There is virtually no situation in the NHS where the default response will not be to organise a meeting.  When emergencies arise, ‘lesser’ meetings are cancelled so that the new, more important meeting can take place.

Integrated care is no different.  It is nearly six years since the Five Year Forward View was published, which was when the idea of integrated care became mainstream.  The idea was to close the divide between health and social care, between physical and mental health, and between primary and secondary care.

There then followed a tsunami of meetings to decide whether an MCP or a PACS (remember them?) would be the best model for integrating care locally.  Integrating care was the clear priority and so that was what filled the meeting schedule.

But 6 years later on it is not clear what impact all of those meetings have actually had.  Now of course the agendas of these meetings have moved on to integrated care systems and integrated care partnerships.  The default NHS response to any new initiative remains having meetings about it, and now PCN CDs are being asked to fill their diaries with these meetings.

The big question then is: should a hard pressed PCN Clinical Director spend any of their valuable time attending these meetings?  If a PCN CD has 2 or 3 sessions a week to carry out the role, how many of them should be spent attending system meetings about integrated care?

The problem with not attending these meetings is the nagging sense that somehow the PCN is missing out.  The concern is that the influence of the PCN will be less if they are not present at these important meetings, or that resources will be diverted elsewhere.

But the reality is that real influence comes from delivering change.  If the PCN is able to build relationships with the local community teams, to find a way of working alongside the local voluntary sector and social care, and to start to make changes happen that make a difference to the local population, not only will the time spent on PCN business become infinitely more worthwhile but also the local system will start to look to your PCN as a place to invest energy and resources.

When the wider system interacts with a PCN, they want to be able to ask the PCN to do something, and once whatever that is has been agreed, they want that to turn into real delivery.  If all PCNs do is turn up to meetings but never delivery anything (because attending the meetings has consumed all of the available time), any influence gained by being at the meeting is quickly lost.  Worse, confidence in PCNs as an enabler of integration is lost and the system starts to look elsewhere for a solution.

A PCN can diligently attend every meeting it is asked to go to and end up with very little influence because it has not had time to make any local changes, whereas a PCN can refuse to attend the majority of meetings it is asked to go to and yet be hugely influential because of what it has achieved.  In the end, delivery will always trump attendance at meetings.

Time is the most precious PCN resource.  PCN CD time and PCN meeting time are extremely limited.  One of the key leadership roles of every PCN CD is to determine how the time available can best be utilised to enable the goals of the PCN to be achieved.  If one of the goals is for the PCN to influence the local agenda, prioritise making change happen locally over attendance at meetings and trust that influence will follow.

Should PCNs Choose the Greater Good?

There are plenty of teams in every sport that have great players and never win titles. Most of the time, those players aren’t willing to sacrifice for the greater good of the team. The funny thing is, in the end, their unwillingness to sacrifice only makes individual goals more difficult to achieve. One thing I believe to the fullest is that if you think and achieve as a team, the individual accolades will take care of themselves.”  Michael Jordan


There is an interesting dilemma facing many practices right now, as they work out how to make the most out of PCNs.  Is it better to maximise the gains for your own individual PCN, or is it better to work together with other PCNs to maximise the gains for general practice as whole?

This manifests itself when a collection of PCNs in an area have to make a decision, and different PCNs have different views.  The decision could be for example whether one individual can represent all of the PCNs in a system-wide meeting.  If that individual can speak as a united voice on behalf of all practices then the overall voice of local practices is stronger.

But that individual may not fully represent the views of “our” PCN.  What if we don’t fully agree with what they say, or don’t trust them to put our point across?  We end up feeling the need to represent ourselves and our own PCN.  But now there are two voices of local general practice.  And if we contradict each other, the overall voice and impact of general practice is diminished.  But at least we know that our individual view and has been represented, and our views fed accurately into the system-wide discussion.

Or maybe we need to decide whether our PCN should use the federation to deliver extended access services, or whether we deliver these directly as a PCN.  If all the PCNs agree to the same model, the overall costs and administration to general practice are likely to be cheaper.

However, an individual PCN may be able to develop its own model which delivers greater retained profits for its member practices.  It may have access to capacity or management capability which mean the cost of delivering directly for that PCN are less than going with the federation model.  In doing so, the costs of using the federation model are likely to go up for the other PCNs and practices (because the fixed costs are then shared between fewer practices).  But at least our PCN has maximised the potential of the opportunity presented.

Should, then, individual PCNs make decisions based on the direct interest of itself and its member practices, or on the greater good of the wider group of local general practices?

The fates of PCNs and practices in an area are actually intertwined, whether PCNs and practices like it or not.  How much a system invests in local general practice overall will be determined by the extent to which general practice is able to both agree amongst itself and collectively deliver.  A system is not going to choose to invest in the medium to long term into one PCN over and above the others in an area, because it will want gains to be delivered to all of its population not just parts of it.

Choosing to take decisions based on maximising the gains of short term opportunities for an induvial PCN is short sighted, particularly when this comes at the expense of neighbouring practices and PCNs.  Operating in isolation will ultimately come at a cost to overall general practice.

What Michael Jordan said applies directly to practices and PCNs within a local area, “If you think and achieve as a team, the individual accolades (gains) will take care of themselves”.

Go Back to the Purpose

We are a year down the line with PCNs.  Recent months have been overshadowed by covid, but there were significant PCN developments in that period.  In particular, the agreement by NHS England to pay 100% rather than 70% cost of the new roles, the rowing back of the service specifications so that now only three (relatively light) specifications need to be delivered this year, and the sign up to the 2020/21 PCN DES by almost all practices.

Last year I don’t think it is unreasonable to say a number of practices, and even whole PCNs, took a ‘wait and see’ attitude towards PCNs.  It was a case of cautious sign up without making any significant commitment.  But now practices are in a whole new position – the role reimbursement scheme funding is significant, the delivery requirement is greater this year, and the extended access funding is around the corner (April next year).  The relative importance, particularly financial, of PCNs to practices is starting to feel different, and so the attitude of practices towards PCNs is beginning to change.

What we are starting to see (understandably) in some areas as a result of this is more unrest within PCNs.  The move from practices taking a relatively passive attitude to one that is more active is inevitably starting to create friction.

This is primarily because GPs and practices often want different things from the PCN.  Should the PCN appoint first contact physiotherapists or more pharmacists?  Should the PCN spend its £1.50 on management support or retain as much of that money as possible for practices?  Should the PCN use the local federation or should it manage its own finances and employment?  There are often different answers to these (and similar) questions within the members of a single PCN.  Moving forward can be difficult.

So how does a PCN move forward in this situation, where practices seem to have differing views on nearly every issue?

The key priority here for PCNs is to work on a shared purpose for the PCN across member practices.  Even if PCNs did this in the early days it may be time now to revisit this given how the landscape has started to shift.  Once there is a clear, shared purpose this can be used as the framework for decision making by the PCN.

Easier said than done.  How exactly do practices develop a shared purpose?  How can practices agree what they want the PCN to achieve?  The key part of this is taking time to sit down together and for each practice to share what they want from the PCN (what we assume is often different to the reality), and then work hard to identify where the common ground lies.

This process may take some time.  The key is to create a framework within which the practices can make decisions together, and criteria to assess any decision against.  If the practices, for example, want the PCN to reduce practice workload, increase the voice of general practice, and improve outcomes for the local frail elderly population, these can become the criteria for assessing any decisions against.  But this will only work if all the practices are agreed and sign up to the framework in the first place, which is why it takes time.

A shared, agreed purpose will not end debates and arguments within a PCN.  There are very few PCNs where the practices agree on everything.  But as the responsibility, funding and influence of PCNs grows, the importance of having a clear direction and a framework to make decisions and settle disputes is greater than ever.

3 Ways to Attract New Roles to your PCN

There is a recruitment challenge facing PCNs this year.  There are over 1,200 PCNs, and each PCN has an average budget of £344,000 to spend on new roles.  This converts to more than 7 roles each, and if the time lag is built in (i.e. most of these roles are not yet in post, despite it being July) it could mean PCNs are recruiting to over 10 roles each.

That means there are potentially over 12,000 new roles being advertised by PCNs all at more or less the same time.  That number of viable candidates does not exist, and so the question facing PCNs is why would potential candidates choose their PCN over another?

The nature of the Additional Role Reimbursement Scheme (ARRS) means that the level of funding available to PCNs for the new roles is fixed, so what is unlikely to happen is that the result will be price competition.  PCNs are not going to offer more money to attract the best candidates.

So how can PCNs differentiate themselves?  This might not be as difficult as it at first appears.  Below are three simple steps a PCN can take to give themselves an edge over the competition.

1.Plan the Role in Advance. PCNs are not experienced employers.  The most likely scenario is that most PCNs will do the work as it arises.  That is to say they will first of all advertise the posts and make offers to the best candidate, but only then work out where the role will be based, how it will be managed, and how it will be supported.  Some may identify exactly what work the new role will undertake in advance, but others will only work this out once the new person is in post.

So if a PCN works out in advance both how the post will operate in practice, and how the role will be supported, it is likely to have a huge advantage over many other PCNs.  This means working out upfront where the role will be based, where the clinical work will take place, who will be the line manager, and who will provide professional support.  It means thinking through the mentoring, coaching, education, and personal development support that will enable the new postholder to be successful in their new role.

These things will have to be worked out anyway.  But a PCN that does this before it starts recruiting, and can provide this information as part of its campaign, will be much more attractive to potential candidates than one that plans to wait until the successful candidate takes up post.


2.Recruit a Team not just Individuals. Working for the first time in general practice can be daunting for candidates.  Many PCNs will recruit to each of the roles individually.  But if a PCN, or even a groups of PCNs, is recruiting (for example) a team of pharmacists or a team of physician associates, and builds team development and peer support into its offer, it is likely to have an edge.  The postholder knowing they wont be entering this new environment alone, but doing so as part of a team, makes taking on the new role less of a risky proposition.


3.Make recruitment personal. Finally, the recruitment campaign itself is an opportunity for PCNs to differentiate themselves.  If PCNs can offer an online platform which provides information about the PCNs and the local area, practices, opportunities and challenges, it is likely to have the edge on many other PCNs.  Even better if it can create a personal connection, e.g. a short video from a GP within the PCN talking about why the role is important, or from a named contact who seems friendly and approachable.

While the bad news is competition is likely to be fierce for the new roles, the good news is that with a little thought and effort your PCN could still be able to attract the best candidates.

Lessons from AccuRx: Resist the urge to control

A few weeks ago I wrote about how AccuRx had changed general practice over the course of a single weekend.  What can we learn from the achievements of a relatively small company like AccuRx, in contrast to the traditional ways of working in the NHS?

The most striking feature of the way AccuRx work is that they do not try and control how the innovation they create is used.  Their belief is that if you prescribe how something is to be used, you actually prevent innovation.

The core AccuRx product is the text messaging service.  They linked the service with the individual patient and their record, but didn’t prescribe how or when the service was to be used.  When practices were working out how to see potential covid patients face to face, some put signs in the car parks for patients to wait in their cars until they received a text message when they were ready to be seen.  Not a way of using the product the company could ever have foreseen!  Innovation in the use of the product came from the GPs and the practices, not from the company.

Equally with the video consultations, practices sent the link for the call to a family member who could interpret for the patient when they didn’t speak English.  In hospitals, it was used to enable virtual visits by relatives not able to visit in person.  Innovation was generated by front line staff, enabled by the initial development.

By resisting the urge to control and dictate how the change was to be used, far more innovation has developed as a result.

In general practice local teams in many parts of the country were allowed to work out how to respond to covid.  “Hot hubs” and the like were developed and locally tailored and implemented in days and weeks.  Without central control, frontline innovation prospered.

This is in contrast, of course, to how we normally introduce change in the NHS.  The urge always is to control.  Trusting front line staff to innovate feels risky because it cannot be predicted.  So what we do is insist on business cases that detail not only the change to be introduced, but exactly how it is be used and implemented, and the predicted impact that will result from the prescribed changed.  The more we control the change, the less risk we feel, but at the same time the more we suppress any wider innovation.

Let’s take PCNs as an example.  The basic change is to enable practices to work together and with local partners to improve outcomes for local populations.  But as an NHS we can’t leave it at that, and allow practices to use the change and innovate locally.  The urge to control is too great.  So instead we have template legal network agreements, detailed service specifications (remember the December drafts?), and maturity matrices.  The NHS attempts to control how PCN will operate, what they will do, and the way in which they will develop.

Resisting the urge to control is very difficult in the NHS.  Senior staff are consistently reminded that they are “accountable”.  The pressure to minimise and control any financial risk is immense, and leaves little room for trusting local staff and teams to innovate.  But the lesson from the success of AccuRx is that less control is exactly what is required to foster greater innovation.

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