Why PCNs are difficult – Part 1

Change is difficult. Changing behaviour is even more difficult. Persuading other people to change their behaviour is even more difficult still. Which is why PCNs are difficult.

The really difficult part of PCNs is that the main benefits come as a result of GPs changing how they work. PCNs have all recently been through the trials of working out how between them they are to cover the extended hours requirements that now fall on the network. The (relatively) easy route is to say everyone has to do their bit. The impact of this is that practices who were choosing not to do it, now have to “choose” to do it. So the impact of the Primary Care Network (so far) on those practices is that they are having to do more work.

At the other end of the spectrum, practices in a PCN work out how they can see each other’s patients. They create a “hub” to carry out extended hours on behalf of all the practices. They expand the remit of the hub beyond extended hours, and into seeing all the on the day demand from the practices across the network. The team seeing the on the day demand is multidisciplinary, led by a GP. The impact on the GPs in the PCN is that they have more time for routine appointments, and they experience some relief from the constant pressure of the daily demand.

The first option does not require GPs to change their clinical practice. They simply have to do more of the same in order to comply with the requirements of the PCN. In that sense it is “easy”, and is why many PCNs have gone down this route.

The second option requires a whole raft of changes. It means all the practices have to agree to the new way of working. It means practices have to trust their patients to be seen by clinicians from other practices. It means the way each practice delivers continuity of care has to change. It means the management of the new urgent care team needs to be agreed. It means when things go wrong practices have to work together to solve the problems as they arise. It requires strong leadership, trust between the practices and a willingness to make changes together.

In summary, it is an extremely difficult option to put into practice, and why most PCNs would have discounted it (or anything similarly disruptive) as an option without much consideration. The opportunity for significant gains is there, but the journey to achieve them is so difficult that they are not realised.

This, incidentally, is the reason many mergers have not made life any better for the GPs involved. Instead of delivering “economies of scale” they have simply led to twice the problems and twice the number of people to engage when any decision needs to be made. In the same way that mergers are not a solution in themselves, but rather create the opportunity for improvement, so PCNs are not a solution for general practice in themselves, but rather create an opportunity for things to be better.

PCNs are an opportunity, but an opportunity that is difficult for practices to exploit. PCNs are difficult because change is difficult, and for PCNs to make a real difference to general practice, real changes need to be made: changes to the way practices work together; changes to the way individual practices in the PCN operate; and changes to the way individual GPs (including those that may not want to make the change) operate.

Making the most of PCN development support

The good news is that £43.5m has been released nationally to support PCN development. This is new money for PCNs, and according to the guidance is “a floor not a ceiling”. The money can only be used for PCN development or PCN Clinical Director (CD) development. “Around 10% of the funds are intended for CD specific development” (expected to be £3,000 – £4,000 per CD).

The process for accessing the funding is relatively straightforward. PCNs are to self-assess their current needs in September, and determine how they want to develop in a support plan. The PCN Maturity Matrix (here) or local version thereof is to be used for this self-assessment. PCNs are also to identify “a specific service improvement priority to focus on as a means for closer collaboration”.

6 development support “domains” have been identified that the guidance suggests PCNs will want to access as they work on their agreed priority: PCN set-up and support, organisational development and change, leadership development and support, supporting collaborative working (MDTs), population health management, and social prescribing and asset based community development.

The PCN identified support plan has to be agreed by “ICSs/STPs, places, CCGs, PCN CDs and other system partners”. In practice for the majority of places this means the CCG and the PCN CD have to agree it. The support is to be mobilised in October. Then “systems and CCGs support PCNs to review progress against PCN priorities and self-assessment” once the support is in place through to March.

There is a parallel process for systems to work with the new PCN CDs to identify their individual and collective development needs and develop tailored plans with support requirements. Once that support has commenced, “with support from systems, PCN CDs review progress against priorities. Areas for additional support identified, revised development plan produced”.

So there is a huge opportunity for PCNs to access a significant chunk of funding that can support the member practices and their work together. There is a risk that accessing the funding becomes the mechanism by which the system exerts management control (i.e. the PCN cannot have the funding unless it is operating in the way in which the system wants it to), and the joint review of progress between the PCN CDs and the system become performance management meetings. But this risk can be mitigated, and the amount of development funding mean it is worth jumping through a few hoops to access it. The key is keeping control of the agenda (which I have written about previously) – if the PCN is clear what it wants to achieve, then this whole process can be worked as an enabler for that.

My main advice to PCNs thinking about their development needs is to differentiate between the internal and external needs. By internal needs, I mean the needs of the member practices, the strength of the relationships between the member practices, and the ability of the practices to work effectively together and deliver services. By external needs, I mean the ability of the PCN to work collaboratively with community services and other teams, to understand the local population health needs, and to be and active partner within the wider STP/ICS system.

I think it is important to prioritise the internal needs first. If practices cannot work together, support each other, agree on priorities, and make changes to delivery across practices, the PCN is very unlikely to be successful. This joint working between the practices is the bedrock of PCN success. All other things will follow if this is in place. So my advice is to prioritise working on the internal needs first, even if both practices (because it can be difficult and threatening) and the system (because they want to widen the focus of PCNs) want more of the initial energy focussed on the external needs.

What is a Primary Care Network?

What is a Primary Care Network? Well? What would you say? It is a question that should be simple to answer, but in reality is not. According to the NHS England website, “They consist of groups of general practices working together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations”. Is that what you were going to say? I didn’t think so…

The NHS England definition feels more like an ambition than a definition. Technically, today, a Primary Care Network is a group of GP practices who have signed up to the Network Contract DES, and who as a result have a Clinical Director and a network agreement in place between the practices. And, as the Network Contract DES Specification states, “There is no requirement for the Network Agreement that is signed by 30 June 2019 to include collaboration between practices and other providers, but this will need to be developed over 2019/20 and to be well developed by the beginning of 2020/21 when the Network Agreement will need to be updated to reflect the new Network Contract DES specification.

Why have GP practices joined primary care networks? Of course for some it is the opportunity to deliver coordinated, integrated care for the local population, but for most it is because access to much of the financial and workforce resources in the new GP contract is dependent on joining. There is an expectation that up to 40% of the additional funding for general practice will come through the new networks, and as the GPC’s initial press release about the new contract said, “Support and funding for Primary Care Networks mean practices can work together, led by a single GP, and employ additional staff to provide a range of services in the local area, ensuring patients have ready access to the right healthcare professional, and helping reduce workload pressures on GPs.”

So we are in this strange limbo position whereby the NHS has introduced Primary Care Networks and created a rhetoric around them that they are to do one thing (co-ordinate and integrate care for local populations), but an establishment of them where the on-the-ground reality is about GP practices working together to secure the investment and resources they need to survive.

This, inevitably, is leading to confusion. The wider system is somewhat bamboozled by Primary Care Networks and the conflicting messages about them, and as a result has no idea what to make of them. “PCN” is being added to the list of acronyms such as QOF, PMS, GMS that make general practice so inaccessible to outsiders. Even practices themselves are not sure whether to keep the PCN at arms-length, and insist that PCN services are kept distinct from the services provided by individual practices, or to embrace the opportunity for cost-saving, income generation and workforce development that PCNs could potentially provide.

But in the midst of this wider confusion there is huge opportunity for practices. If practices can maintain clarity on exactly what a PCN is (as defined by their contract), keeping in mind that the contractual requirements will change and evolve, it actually puts them in a strong position. They can focus on maximising the opportunities of PCNs for their practices for now, and on ensuring that as the system asks for more from PCNs (as it inevitably will) that appropriate funding follows.

Primary Care Networks: Who sets the agenda?

It has been a challenging start for Primary Care Networks (PCNs). From first settling the membership and getting the network agreement signed, to then immediately having to tackle any half day closure issues and practices who were not providing extended hours, it is fair to say the journey so far has not been easy. But where does the focus now lie for PCNs?

The risk for PCNs is that they continue to be recipients of an agenda and a timetable set by others. Now PCNs are in place, there are a plethora of organisations and individuals keen to meet them and talk about their work and their programme and how the PCN can support it. The number of meeting requests for the new PCN CDs is growing, and will doubtless accelerate once the holidays are over and September arrives.

PCNs are different from CCGs and other NHS organisations, in that they are not statutory bodies. The NHS hierarchy has no formal control over them. Born out of the GP contract, they are contractual constructs and as such are independent contractors in the same way that GP practices are. If it is not in the contract, the PCN can choose not to do it.

There is a power in this position. Clearly it is going to be in the interest of the PCN to build constructive relationships with other organisations (even if the primary motivation is to make delivering the future contractual requirements easier!), and to take actions to support the local population. But this is different to letting others set the agenda for your PCN, in terms of what it is trying to do and what it spends its time discussing and working on.

The establishment of a PCN is an exercise in change management for general practice. Changes succeed or fail depending on the extent to which the problem the change is trying to solve is clear, the extent to which those involved in the change are bought in to solving the identified problem together, and the ability to show progress over time towards solving the problem (I would strongly recommend you take half an hour to read this book if you haven’t already).

This means to be successful PCNs need to exist not because the contract mandates that they do, but as an enabler to solving the problem(s) the practices have identified. It is critical PCN practices spend time agreeing exactly how they want to maximise the benefit of the new PCN, whether that is the outcomes for the local population, the financial sustainability of the member practices, the workload of the member GP partners, or whatever the key local challenges are.

Once this is clear, setting the agenda is much more straightforward. The PCN will prioritise anything that supports delivery of its aim, and de-prioritise anything that does not. Control of the agenda comes from the PCN itself, not from outside. If progress is monitored by the use of some agreed regular measurements, this focus will remain in place as the months progress.

But without a clear purpose, PCNs run the risk that their agenda will be set by others, that they will achieve very little that makes a difference locally, and that any initial enthusiasm and support from practices will quickly wane. As the contractual requirements lessen for the remainder of the year, and as PCN development monies emerge, if you have not done so already now is the time for member practices to establish and agree what they want the PCN to achieve, and then to make sure it controls the agenda and how its precious time is used to ensuring that goal is delivered.

 

Should PCNs have a national voice?

There was an interesting recent debate on one of the national WhatsApp groups about whether there is a role for an independent national PCN voice. Opinion was divided, with strong proponents both for and against.

The argument for goes along the lines that PCNs are something new (with a new cadre of PCN Clinical Directors) doing something different and more inclusive than general practice, and hence need to be represented at a national level in a different way to the GPC/how core general practice is represented.

I think there are two main reasons why this is not a good idea. First, it will weaken the national voice of general practice. General practice remains in crisis, despite the new contract and the formation of PCNs. It is critical that general practice retains a strong national voice. It currently has this through the GPC. If a separate voice for PCNs develops, it risks enabling the government, NHS England and national bodies to bypass the GPC, and push initiatives and new ways of working onto general practice via the PCN route. The greater dependence general practice has on PCN funding, the greater this risk becomes.

Second, it could limit local PCN flexibility. There are people working hard to try and enable the development of PCNs to be determined at a local level. One of the key strengths of PCNs is as local network enablers, bringing general practice together with a wide range of local stakeholders for the betterment of local outcomes. Each place is different, and will need different strategies and ways of working, and (more importantly) will want to control how this happens for itself. The old mentality of being dictated to from on-high needs to be replaced with a vibrant local determinism, a shift far less likely to happen if a national PCN representative body exists.

PCNs do, however, need a strong voice within their local integrated care system (ICS). Part of the PCN Clinical Director role is to represent the PCN within the local ICS, and how effectively this happens may determine whether there is any overall shift of resources (and workload) from secondary to primary care, and whether the system invests in primary care.

The key to this voice being strong is for general practice to ensure it presents a united front locally. If general practice is represented by a federation, the LMC and PCNs, none of whom can agree on what they want or how they want it, the voice is divided and the overall voice is diluted. Ultimately this internal division will end up in less resource being shifted to primary care.

The desire for a separate PCN voice comes from a sense of some GPs and practices not feeling represented. The solution, however, is not to create a separate voice for them, but to work hard to establish an inclusive, strong, unified voice for general practice, and to work to overcome the often historic barriers and disputes that exist within general practice for the benefit of all.

Here at Ockham Healthcare we have produced a free guide for PCNs which outlines 10 practical steps for PCNs to establish a powerful voice. It is free for subscribers – to subscribe simply click here. A unified PCN voice at a system level, and a single general practice voice at a national level, will maximise the overall impact of general practice on the system, and increase its chances of emerging from its current challenges.

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