What has the PCN ever done for us?

There is a tension that sits at the heart of any PCN.  It is the mismatch between the practice expectation of a PCN (that it will support the practice and enable it to be sustainable at a time when GP practices are struggling), and the system expectation of it (that it will work as a force for integration at a local level and unite services around the needs of local populations).

This tension sits primarily on the shoulders of PCN Clinical Directors.  These individuals spend much of their time trying to engage their member practices in the PCN project, practices that are often asking the question of what the PCN has ever done for us.  At the same time the weight of system expectation is that they will form productive alliances with the local (sometimes failing) mental health trust to introduce mental health practitioners, or the local (under pressure) ambulance service to magic up new paramedics, or interface effectively with a whole regional infrastructure that drags the PCN social prescribers away from what the practices want from them.

What is the role of the PCN?  Is it to support member practices, and act as a vehicle for the introduction of additional roles that will sustain them in the absence of any more GPs?  Or is to tackle health inequalities and help ensure the needs of local communities that have often been overlooked finally start to be met?

The fundamental problem with the whole PCN agenda is that the answer to this question is not clear.  It feels like their introduction was a compromise, an attempt to try and do both of these things at once.  The problem is that it was sold to practices on the basis of their future sustainability (remember £1.8bn of the additional £2.8bn promised to general practice in the 2019 5 year contract was via PCNs), and at the same time sold to the system as providing the building blocks of the new integrated care system.

The problem with compromise is that it often means no one wins.  In social psychology studies of groups, compromise is considered lose-lose in a zero sum equation.  Both parties want 100%, but they both have to give something up to appease the other party.  As a result, neither party really gets all of what they want.  Typically it results in resentment and not really being happy.

This feels like where we are now.  General practice is not happy with the PCN DES, as was clearly signposted by the inclusion of resignation from it as part of the move towards industrial action.  At the same time the system is not happy with PCNs and the role they are playing in the developing integration landscape, or else why would they have been replaced by “neighbourhoods” in the recent White Paper?

This is all starting to feel like a missed opportunity.  There is no reason why PCNs cannot meet both agendas, and contribute to the sustainability of practices and enable meaningful local integration.  But what this requires is an explicit acknowledgement by all that PCNs are trying to do both of these things.  Their success should be measured by the extent to which it achieves both of these goals.

At present there is no marker of what PCNs have done for practices.  There is no reason not to make this explicit, and include it front and centre of what PCNs achieve.  At the same time the PCN DES measures that we do have are national markers (because it is a national contract) of the role of PCNs in integration.  But of course for them to be really effective in this role these measures need to be locally set – the challenges in Frimley are not the same as the challenges in Newham.

So instead of trying (badly) to do two different things for two different audiences, it would better for PCNs to be explicit about the dual goals to everyone, have appropriate separate measures for each, and be given the freedom to use the resources that are being made available to make both things happen.

What the Integration White Paper means for General Practice

The government published its White Paper “Joining up Care for People, Places and Populations” on the 9th February, describing itself as “the government’s proposals for health and care integration”.  This is apparently one of a set of reforms, as it sits alongside the Health and Social Care Bill and the Adult Social Care Reform white paper.

There is no getting away from the meaningless fluff that surrounds descriptions of integration in the paper (e.g. “Successful integration is the planning, commissioning and delivery of co-ordinated, joined up and seamless services to support people to live healthy, independent and dignified lives and which improves outcomes for the population as a whole” p17).  The terminology within the paper is both over the top and (at best) confusing.

The paper clarifies (p18) that a “neighbourhood” is “an area covered by, for example, primary care and their community partners”.  You would think this would be called a PCN, but the PCN nomenclature appears to be have been dropped within this paper and replaced by neighbourhood.  A “place” is a locally defined geographic area typically 250-500k population, and a “system” is a larger area with a population of about 1 million.

In fact PCNs only get one significant mention in the paper, and that is primarily to signpost the fact that they are being reviewed, “GP practices are already working together with community health services, mental health, social care, pharmacy, hospital and voluntary services in their local areas in groups of practices known as Primary Care Networks (PCNs). Building on existing primary care services, they are enabling greater provision of proactive, personalised, coordinated and more integrated health and social care for people closer to home. NHS Chief Executive, Amanda Pritchard, has asked Dr Claire Fuller (CEO Surrey Heartlands ICS) to lead a stocktake of how systems can enable more integrated primary care at neighbourhood and place, making an even more significant impact on improving the health of their local communities. This will report later in the spring.”

For a reason that I am not clear on, PCNs have shifted from being the central plank and foundation of integrated care systems, to something that contribute towards the overall ambition for integration – make of that that what you will.

The paper tries to distinguish between what will happen at the system level and at a place level.  There is the sticky issue of whether the NHS or Local Authority is “in charge” at a place level, and the solution the paper comes up with is that, “There should be a single person, accountable for shared outcomes in each place or local area, working with local partners (e.g. an individual with a dual role across health and care or an individual who leads a place-based governance arrangement).” p11.

However, “These proposals will not change the current local democratic accountability or formal Accountable Officer duties within local authorities or those of the ICB and its Chief Executive”, which does rather beg the question of what power or authority these newly accountable individuals will have.

The suggested governance model for place is via a ‘place board’, “a ‘place board’ brings together partner organisations to pool resources, make decisions and plan jointly… In this system the council and ICB would delegate their functions and budgets to the board” p34.

General practice therefore needs to work out how it is able to be an effective member of, and be able to influence, this place board.  This will inevitably require the PCNs within a place area to find ways of working together and to be able to create a unified voice.

The autonomy of these place boards is still open to question.  Despite a lot of rhetoric about the need for local areas to determine local priorities, the pull of the top down approach has once again proved too difficult to resist, “We will set out a framework with a focused set of national priorities and an approach from which places can develop additional local priorities” (p23).   A new set of national priorities is on its way for implementation from April 2023.  This means places will receive their must-do list which they will undoubtedly be heavily performance managed on, but of course can also set some additional priorities for themselves if they would like.

That said, the ambition remains for services and spend to be put under the control of place based arrangements, so I still think it would be wise for general practice to ensure it plays a central role within them.  One thing the paper is clear on is that general practice funding is not to be ringfenced from other spending, but rather included within a single system funding envelope (p36).

There are promises to have fully integrated shared care records across organisations and seamless data flows across all care settings in place by 2024, but if the last 20 years has taught us anything it is don’t hold your breath.

There is a whole chapter on workforce integration.  What is notable about this is more what it doesn’t say than what it does.  It talks about the pivotal role of link workers and care navigators in joining up care, about pharmacist integration, and about making better use of occupational therapists, but it never once references the additional roles coming into PCNs through the ARRS.

Overall the paper continues the national drive towards integration, and reinforces the need for general practice to make sure it is playing a central role in the developing place based arrangements for their area.  What is potentially of most concern is the shift away from the importance of PCNs and whatever lies underneath that.

The Challenge of Being a PCN Clinical Director

The role of a PCN Clinical Director is more challenging than it has ever been before, and yet we are about to see a huge turnover in those undertaking these roles.  Why is the role so different now, and how can those taking it on for the first time now even hope to be successful?

It may not feel like it, but it is now three years since we were first introduced to Primary Care Networks (PCNs).  They first appeared in the NHS Long Term Plan which was published in January 2019, which was then quickly followed up with the new five year GP contract the following month with the PCN DES for general practice.

After three months of set up, PCNs were formally established on 1 July 2019.  One of the requirements was that each PCN had a Clinical Director in place.  Many of these Clinical Directors agreed to take on the role for an initial term of 3 years.

Unfortunately the initial funding of 0.25wte per 50,000 population was wholly inadequate for the workload and expectation placed upon these new leaders.  This situation was not helped by the ongoing national refusal to make any funding available for PCN managers to lighten the burden on PCN CDs.  Whilst the funding has (belatedly) been temporarily increased to 1 wte and some (non-recurrent) funding has been made available for management support this year, it has never been done in a way that allows PCNs to invest more into PCN leadership on a permanent basis, or that enables those leaders to give up their other work and create more time for the role.

The PCN CD role has changed immeasurably in the last three years.  In their first year the (not insignificant) challenge was persuading practices to work together.  But since then PCN CDs have had to deal with Covid, the vaccination programme, a huge increase in staffing via the ARRS scheme, and an ever increasing set of delivery requirements, all during a period of transition into integrated care systems.

Let’s not forget, all of this has been set within a context of general unease across the service with PCNs.  At a number of points across the last three years there have been threats of widespread resignations from the PCN DES, and that threat is still hanging following the ballot from November last year.

It is no surprise, then, that many of those who put themselves forward to be a PCN Clinical Director back in 2019 are saying that enough is enough, and that it is someone else’s turn to carry the baton now that the initial three year term is up.

The problem is that most of these individuals have grown and developed with the role over the last three years.  They possess leadership skills and experience that they did not have when they started.  Their PCNs need them in the CD role now more than they ever did.  But the system has treated them in a way that means it is unsurprising that many do not want to continue.

And so we are in a position where in many PCNs, someone new, or maybe even two new people, are taking on the role.  The challenge for these new incumbents is even greater than it was for their predecessors because the roles are so much bigger now, and the expectations on PCNs are so much higher.

It will not be easy, and it will be down to both the local practices within a PCN and the local system to support this new wave of leaders so that they may also have a chance of success within the role.

It is with all of this in mind that myself, along with PCN CD Dr Hussain Gandhi and PCN expert Tara Humphrey, have set up PCN Plus.  PCN Plus is a development programme for those taking on the PCN Clinical Director role, and provides training for new PCN leaders in how to be successful in the role.  You can find more information about PCN Plus here.

The Influence of General Practice on Integrated Care Systems

The shift to Integrated Care Systems is going to be a difficult one for general practice.  The luxury of Clinical Commissioning Groups (whatever you might think of them) was that they put general practice at the forefront of decision-making.  Of course that is not really how they worked out in practice, but at least their existence ensured a strong presence for general practice in any system-wide decision making.

That, however, is all about to change.  It may well be that the statutory change to Integrated Care Systems and the formal abolition of CCGs is not due to take place until July, but these changes  are already being made and the new system will be up and running sooner rather than later.  The statutory representation of general practice falls to a solitary GP on the ICS Board, and they will have no requirement to be there in a representative capacity for the profession.

In a recent podcast with Dr Jaweeda Idoo from Greater Manchester, where devolution has accelerated the ICS agenda, it became clear that there are numerous levels between any individual practice and the ICS Board.  Each practice is in a PCN.  Each PCN works together with other PCNs in a “place” area.  The 10 place areas from across general practice work together in a general practice board for Greater Manchester.  Representatives from the general practice board are on the primary care board (incorporating wider primary care partners such as pharmacists, opticians and dentists).  Representatives from the primary care board sit on the Provider Board.   The full ICS Board then also includes CCG and Local Authority representatives.

There are a lot of layers.  The distance between a practice and the ICS seems vast.

In Greater Manchester general practice has retained a voice, but this seems to be due to the influence of certain individuals, such as Manchester LMC CEO Dr Tracey Vell, and a seemingly shared belief in the pivotal role general practice plays within the system.

But Integrated Care Systems are not being designed to maximise the voice of general practice.  Instead we have this sense of predatory hospital trusts, encouraged by the Secretary of State, considering how they can bring general practice under their wing and keep their needs central within ICS discussions.  Practices in areas more dismissive of the role of general practice than Greater Manchester may find themselves even further down the pecking order.

What, then, is general practice to do?  There is a school of thought that the only way to increase the influence of general practice is to make the service more relevant to the system discussions.  By doing more to impact the system, such as taking on outpatient and more minor procedures from the acute environment, or managing cohorts of the unwell at home, then it forces the system to listen.

There is another school of thought that general practice has not only react to proposals put forward by others (which appears to be the default system position), but must proactively generate ideas and strategies of its own in order to increase its sway in the discussions.  By bringing new things to the table general practice can create its own relevance.

While either of these things may or may not turn out to be true, my sense remains that the starting point has to be the development of a sense of unity and collective identity across general practice in any area.  At present general practice often feels divided between practice GPs, PCN CDs, Federation Directors, CCG GPs, LMC GPs, and even CCG primary care teams.  In the new system, however general practice chooses to work to generate influence, it has to do it together.  There can only be one general practice “team”, and everyone has to be on it.

For leaders in general practice preparing for the shift to Integrated Care Systems the most pressing priority right now has to be working to create this unity.  Divisions in the service sometimes run deep, but it is in everyone’s interests to put these to one side, to bring together all the skills and expertise that exist across the service, and work to unite these to give general practice the best possible chance of meaningful influence in the new system.

Why Would Sajid Javid Claim to Want to Nationalise General Practice?

On Saturday the Times reported a plan by Sajid Javid to ‘nationalise’ general practice.  It seems (once again) general practice has become something of a political football.  What are we to make of this latest report?

We need to put this latest development within the context of everything that has happened in recent months.  In October last year the government, clearly frustrated by complaints in the Mail and other elements of the press about challenges with access to a face to face appointment for a GP, pushed NHS England into the production of their document “Our plan for improving access for patients and supporting general practice”.

As a result the profession, already incensed by the lack of support from NHS England earlier in the year over the same issue, voted in support of a mandate for strike action.  Not, one would think, the response the government was looking for.

At this point (in November last year) the Health and Social Care Committee, now led by a transformed Jeremy Hunt seeking to use his position chairing this committee to undermine the government at any point, launched an Inquiry into the Future of General Practice.  Evidence for this inquiry can be submitted until this Friday, 4th February.

The Times article indicated that a review of General Practice is “planned” by Javid, so we can assume this is not the same as the Health and Social Care Committee Inquiry.  There are undoubtedly politics that we are not aware of between Hunt and Javid also at play, but what the Secretary of State certainly won’t want is Hunt’s Committee telling him what he should be doing with general practice.

The other important piece of context for this article is the wider shift to integrated care, and what this means for general practice.  As I discussed a couple of weeks’ ago, the Planning Guidance for the NHS seems very geared towards the role general practice can play in support of acute trusts, in particular in relation to the rollout of thousands of virtual wards.

A review of PCNs was also announced in November last year, and interestingly this review is now framing itself in terms of what “integrated primary care” looks like.  In this video the leader of the review Clare Fuller does not reference PCNs once.  This review is due to report next month, so it is not beyond the realms of imagination to think that this is the review that Javid is referencing in the Times article.

This would also explain the timing of the article, although of course all this is being carried out at exactly the time that the newly elected GPC committee, armed with their strike mandate, are negotiating the first contract.  This government, for longer than most of us can remember, wants better access to a GP above all and everything else, and if negotiations are not going well this might be the perfect time to threaten nationalisation to move things along.

The argument for organising health services around the needs of hospitals (as opposed to the health needs of the population) is so antiquated that it is hard to believe that it is being taken seriously.  That said, with this government anything is possible, and there are disturbing trends within Integrated Care Systems and the guidance around them towards creating primacy for the needs of hospitals.

But overall my sense is that general practice has very much become a political football, and that most of this is political game playing.  I don’t really think Sajid Javid wants to nationalise general practice, and to end up in a full on dispute with the profession, but I think there are things that he does want and reports like this are simply a means to help him get them.

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