What’s next for PCNs: The first 100 days…

You made it! The 1st July has come and gone. The Primary Care Network is in place, the network agreement (largely) agreed and signed, you have a way forward on extended hours, and now you are “live”. But what is next for the PCN Clinical Director? Now you are officially on the payroll, it is time for the first 100 days.

Senior leaders often start new roles with a plan for their first 100 days. They are important because they set the tone for how things will be under your leadership. Here are seven things for new PCN Clinical Directors to consider making part of your 100-day plan.

1 Focus on relationships over delivery

The biggest mistake eager new leaders make is to have an almost zealous focus on delivering sweeping changes as early as possible in their tenure. They feel the need to prove themselves in the job by showing they can make change happen fast.

Practices are already nervous about the introduction of PCNs. A new PCN CD dictating to practices how things are going to be within a few weeks of taking on the role is going to make these feelings worse. Even if you are able to bulldoze through how the pharmacist is going to work in every practice, it will be at the cost of the trust, discretionary effort, and support that you will need going forward.

Instead, focus on listening to practices, understanding their different needs and challenges, and the concerns and hopes they have about PCNs. At the same time, identify the key leaders in the community, mental health and voluntary organisations in your area. Ask to meet them, don’t wait for them to approach you. A network of strong relationships will be essential for future success.

2 Ensure a communication system is in place

Communication across all members of a practice is not always great.   If practices don’t know what the PCN is up to, mistrust will grow. The challenge for PCNs is enabling two-way communication across a group of practices. Ask practices what they want – a WhatsApp group, a weekly email, or whatever will work locally, and how often, and put it in place. If you achieve nothing other than putting an effective communication system in place you can consider your first 100 days a success!

3 Agree what success for the PCN looks like

You may be one of the few PCNs who before they got lost in the details of network agreements and extended hours took time to agree what the PCN was for, what its purpose was, and how success would be measured. But if not, now is the time for the PCN CD to find out from practices what success for the PCN means to them, and then to play back something that all can relate to, so both you and the practices are clear on what exactly it is you are trying to do in your role as PCN CD.

4 Under-promise and over-deliver

This sounds simple, but all too often new leaders make grand promises early on to try and build support based on what they are going to do. They then spend the rest of their time having to explain why they haven’t lived up to their initial claims. It is far better to be cautious in what you say you can deliver, and to build trust as you go by not only consistently doing what you said you would do, but often times achieving considerably more.

5 Select the Meetings you attend carefully

The NHS has a nasty habit of taking new leaders and swamping them with more meetings than it is possible for any diary to bear. The challenge in your first 100 days is to keep as much control of your time as you can. You must decide the meetings you go to; do not let the system decide for you. Ultimately you will be judged on the success of your network, not on the number of meetings you have attended. If you are always in meetings you will have very little time for real delivery, and very little time for the visible presence you will need at practice level to build that all-important support and trust.

6 Find your personal support

Leadership is lonely. You will, however supportive practices are right now, have to make some very tough and most likely unpopular decisions. There will be times when choosing the right way forward will be hard, and you won’t know what to do. These are the times when you will need support; people you can turn to who you can trust and who will help you work things through. Better to find this support and have it in place before you need it, rather than wait until the inevitable crisis arises. It may be a trusted colleague in your PCN, the CD of a neighbouring PCN (you are all on the same side), or someone else whose experience and opinion you value. Make finding this support a priority for your first 100 days.

7 Deliver some small wins

Now remember you are not trying to deliver any sweeping changes in your first 100 days. By small win we are not talking about anything major. But if from your conversations with practices, listening to GPs, and meeting local stakeholders there are things you see that can be done that are relatively easy to implement (without generating antibodies!) then make them happen. No one is expecting a miracle straight away, and setting a tone of positive change can create momentum for the bigger challenges ahead.

Pack or pride – how should PCNs operate?

The strength of the pack is the wolf, and the strength of the wolf is the pack.” Rudyard Kipling

There is a nervousness amongst GP practices in the intertwining of their fates with those of other practices through PCNs.  The move to robust PCN network agreements can be about protecting the higher performing practices from being ‘dragged’ down by those who are not doing so well.

Equally, as GP practices choose the PCN they are to be part of, there is a tendency for competitiveness between PCNs to emerge.  Instinctively many GPs and practices want “their” PCN to be more successful than those around it, thus justifying the choice of the practice to join it in the first place.

Anyone working in general practice at present understands the pressure that the sector as a whole is under.  When faced with such an existential challenge, there is real value in working together to meet the challenges rather than shifting to a ‘survival of the fittest’ type attitude.

This is perfectly illustrated when considering the respective plight of lions and wolves.  It is estimated there are 20-30,000 lions left in Africa.  50 years ago there were 450,000 lions, a decline of more than 95%.  While historically their numbers had grown, the emergence of man as a predator of lions is the major factor behind their decline.

However, what is astonishing is that the majority of lions are still killed by other lions.  In some prides 80% of the cubs don’t survive.  Either they are killed by other males, or they don’t get enough to eat (they typically eat last in the hierarchy of the pride).  Lions evolved without a predator with an instinct to dominate the savanna from each other, not to share it.

The similar emergence of man as a predator of wolves resulted in the number of wolves declining by about a third.  However, their population is now relatively stable at about 300,000.  Wolves care for each other as individuals.  They form friendships and nurture their own sick and injured.  Pack structure enables communication, the education of the young, and the transfer of knowledge across generations.  The older wolves, as more experienced hunters, share hunting strategies and techniques with younger wolves, passing down knowledge from one generation to the next.

While lions collectively struggle because of their individual desire for dominance, wolves succeed because they cooperate and support each other.

The lessons for newly formed PCNs are clear.  Do we build PCN governance structures to ensure the most successful practices aren’t negatively affected by the practices that are not performing as well, or is the aim to support all practices regardless of their starting point, and to help those most in need to improve?  Do we share information, ideas, resources, expertise with other PCNs, or do we keep it to ourselves and leave other PCNS to work it out for themselves?  Do we collaborate with other PCNs to create a strong voice for general practice, or do we let inter-practice and inter-PCN disputes weaken our collective stance, as we argue against each other in public so that others can simply ignore the general practice position?

We should judge PCNs not on how they are performing relative to other PCNs, with metrics devised by the system, but on how well they are supporting their member practices, and the extent to which they are enabling general practice to thrive.  The more both practices within a PCN work collaboratively together, and PCNs work collaboratively together with each other, the more general practice will thrive.  It may even be we get to a place where “the strength of the PCN is the practice, and the strength of the practice is the PCN”!

What is your Primary Care Network’s Purpose?

I was sitting in a nascent PCN’s meeting recently, and watching the practices grapple with the challenges of forming a new network, and at the same time thinking of the quite common advice for PCNs to establish a common purpose.  Sitting there, I imagined saying to the practices that what they needed to do was spend time identifying and agreeing a common purpose, and equally visualised my rather speedy subsequent removal from the room.

I understand that forward thinking practices can get to the place of considering what the purpose is of their shared network.  But for most practices the current challenges are agreeing who will be in the network, who will be the leader, how they will make decisions, who will hold the money, and how they will deliver extended hours.  There is no time (or patience) for esoteric questions about purpose, when there is so much that needs to be done in the little time they have together.

Does that therefore mean that those PCNs who have not explicitly addressed the question do not have a purpose?  Or is the (unspoken) purpose enabling practices to do what they need to do to fulfil the contract, and receive the funding and resources to which they are entitled?  If there is no purpose at all, you could argue practices would have rejected the Network Contract DES.

Framed more positively, is, then, the (unspoken) purpose of PCNs to increase investment in, and the sustainability, of general practice?  Is it to reverse historic underinvestment and enable general practice to emerge from its current crisis?  Are PCNs in fact a “lifeboat” (as it was termed at a recent Nuffield Trust event) for general practice?

I co-authored a book entitled the Future of General Practice, in which we explored what practices who had emerged from the current crisis had done.  Broadly speaking they have introduced new roles, found ways of working at scale, and began to form partnerships with other providers in the wider system – all elements of the new PCNs.  Like them or loathe them, there is no doubt PCNs represent an opportunity for general practice to create a more sustainable future for itself.

Is it ok for the purpose of PCNs to be first and foremost about investment in and the sustainability of general practice?  As we discussed last week, the system wants PCNs to be about the integration of general practice with the wider system.  And can anything in the NHS be about anything other than improving outcomes for patients?

I would argue that if the system partners with a general practice that is essentially broken, the benefits will be limited.  And if supporting general practice is the way to improve outcomes for patients, then it is perfectly reasonable for that to be its primary goal.  Where general practice is in crisis, the purpose of PCNs needs to be to support them out of it.  Integration with the wider system, and improved outcomes for patients, will be happy bi-products of this primary purpose being fulfilled.

The challenge for PCN leaders is to be clear on the purpose of their PCN.  While the discussion might not explicitly have been had, GP leaders will know why their colleagues are turning up and what their expectations are.  I think there is actually real value in these leaders making the implicit explicit, and using this positive articulation of exactly what it is practices are doing together to give energy to the PCN from member practices.  Ultimately, practices, the wider system and patients will all benefit from this.

What are PCNs: joint working between practices, or something more?

There is an almost palpable dissonance that sits between the Primary Care Networks (PCNs) as constituted in the PCN DES, and how they are perceived in the minds of CCG leaders and those responsible for developing integrated care systems.

On the one hand the GP contract portrays the DES as a framework for practices to work together and to secure investment into general practice over the coming years.  The system, meanwhile, seems to think of PCNs as the building blocks of the local integrated care system, with a membership and remit expanding far beyond core general practice.

So who is right? Are PCNs a contractual construct of joint working between practices, operating solely within the framework of the national GP contract, or are they something more, owned more widely across the system and with an accountability beyond the terms of the GP contract?

This question is one general practice would do well to take time to consider, because the implications are far reaching.

A good place to start is the Long Term Plan for the NHS, published just before the new GP contract.  In chapter 1 of this document, which sets the direction for the NHS for the next 5 years, it sets out five major changes to the NHS service model, the very first of which is “we will boost ‘out-of-hospital’ care, and finally dissolve the historic divide between primary and community services” (Long Term Plan p12).

How will this be achieved?  Through PCNs. Through the investment of £4.5bn in “expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices… Most CCGs have local contracts for enhanced services and these will normally be added to the network contract… The result will be the creation – for the first time since the NHS was set up in 1948 – of fully integrated community-based health care” (Long Term Plan 1.9-1.10 pp 14-15).

There are some important points to note here.  First is that, in case anyone is in any doubt, the primary purpose of PCNs is the integration of primary care with the rest of the system.  The contract has been used as a necessary mechanism for setting them up.  How else can you integrate independent contractors?

Second, is that the promised £4.5bn in the Long Term Plan is considerably higher than the £1.8bn promised in the GP contract to support the formation of PCNs.  This is because the majority of investment in PCNs will not be through the core GP contract.  The funding that comes from other sources (which, by the way, represents a huge opportunity for general practice) will, inevitably, bring with it an accountability outside of the core contract, and into the wider system.

The other place to look is the PCN Network Contract DES, which notes the key features of the DES are set out in the Long Term Plan (and so references the points above without explicitly stating them).  It says the DES is subject to annual review and development, and that the focus in 2019/20 is “to support the establishment of PCNs and the recruitment of the new workforce, with the bulk of the service requirements coming in from April 2020 onwards” (Network Contact DES Specification p5).

So this year (the easy one) is about practices working together, and essentially getting ready for what is to come from 2020 onwards.  That is when the shift will accelerate away from core general practice.  The Network Contract DES guidance states, “PCNs will increasingly need to work with other non-GP providers, as part of collaborative primary care networks, in order to offer their local populations more personalised, coordinated health and social care. To support this, the Network Contract DES will be amended from 2020/21 to include collaboration with non-GP providers as a requirement. The Network Agreement will be the formal basis for working with other non-GP providers and community based organisations.” (p16-17).

One of the service specifications coming in 2020/21 is the innocuous-sounding anticipatory care, “The Anticipatory Care Service will need to be delivered by a fully integrated primary and community health team. To support this, from July 2019 community providers are being asked to configure their teams on PCN footprints. The requirements will be developed across the country by ICSs, and commissioned by CCGs from their PCNs. NHS England will develop the national requirements for the essential contribution required under the Network Contract DES.” (p18).  Within one of seven DES service specifications the NHS has effectively announced the full integration of primary and community care!

Back to the original question – are PCNs about contractual joint working between practices, or about integrating all services within a local community?  While today the answer is largely the former, it is clear from 2020 onwards the answer is very much the latter.  There is no real dissonance (other than between the expectations of pace setting system leaders and the reality of where their local networks are).  PCNs are on a journey.  The start of this journey (and where we are today) is joint working between practices, but very quickly this will evolve into joint working between that group of practices and the rest of the local health and social care economy.  This is the DES practices have signed up to, and these are the changes that are on their way.

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