Why the new PCN DES Specification matters to everyone, not just general practice

There is a huge furore at present in general practice as a result of the publication of the draft PCN DES specification for 2020/21.  There are hugely detailed requirements on PCNs without any additional resource, and a clear expectation that the new workforce outlined in the 5 year GP contract last year is for additional work rather than to help meet the existing pressures in general practice.  Unsurprising, then, that general practice has reacted how it has.

But the implications of the draft specification go beyond general practice.  It is material to whether the shift away from the commissioner/provider split and towards integrated care, as outlined in the Long Term Plan, will succeed.

For integration to have an impact it needs local innovation, driven at a local level, based on trusting local relationships.  But as Integrated Care Systems (ICSs) and Integrated Care Partnerships (ICPs) try to meet testing national deadlines, their focus has shifted to governance, and the traditional NHS focus on accountability, control and decision making.

We have moved the deck chairs around enough times to know already that this will make no difference.  The one opportunity for it ‘to be different this time’ is PCNs.  Their 30-50,000 size enables real localism, borne out of an understanding of what is needed and what will work in each area, with person to person relationships as the enabler of making real change happen quickly.

The job of the architects of the new system really is to create the space, time and freedom for these local relationships to develop, for local problem solving to begin, and for local solutions to be developed.  So, for example, if a group of practices has a problem with the way district nursing is being delivered, instead of them raising that with the CCG to raise with the community trust in a contract meeting, who in turn will raise internally, and very little will happen, we move to a system where the practice leaders meet the district nurse leaders (who they already know) and work out what they can do differently to offer a better service to patients.  A system like this is one where things could start to be different.

The biggest problem with the PCN DES specification is the signal it gives that this will not be allowed to happen.  This is for three reasons.  The first is that if the centre dictates what PCNs should do in anything like the level of detail that is in the draft specifications, local innovation will not be able to flourish.  The mindset of central control has to be given up if integrated care is going to work, because the best solution in one area will not be the same in another, and each area needs the freedom to work out what will work best for them.

The second reason is that it has to be up to local areas to determine how they will use their workforce, and not nationally dictated.  The individual ‘return on investment’ mindset of any new funding, and a requirement for additionality even when core services are floundering, is fundamentally flawed.  We know we are 5-6,000 GPs short.  The new PCN-funded workforce can help both support general practice to thrive and be an enabler for local system working, but it has to be for local areas to decide how this workforce should be deployed across priorities (including core work), not via a nationally dictated contract.  Defining the “additionality” that new roles must deliver misses the point that existing (potentially more important) requirements cannot currently be met, and each local area has to be free to determine how to deploy the new roles to get the most out of them.

The third reason is that it takes time for local relationships to develop.  In year one we have had a primary focus on practice to practice relationships.  In year two we do need to widen that focus to the relationships across the wider group of providers within each network.  Time is needed for trust to develop, and over-burdening local areas with the level of delivery requirements contained in the draft specification at this stage runs a high risk of making relationships worse not better.  We need patience as we build a platform for future success.

My plea is for system leaders to recognise that the underpinning approach encapsulated within the PCN DES specification is one that will prevent the success of the new systems they are trying to create, and that it is not simply a general practice only contractual dispute.  If PCNs are really going to be the engine of integrated care, this contract needs to be an enabler not a dictator of local change.  Getting this contract right is everyone’s responsibility, and it would be great to see local leaders vocalising their own concerns about the issues the draft specification raises.

What to Make of the Draft PCN Service Specifications

The draft PCN service specifications were finally released just in time to put a dampener on Christmas for anyone eager enough to read them that quickly.  If you have avoided that particular pleasure so far, you can find them here.

It is worth stating right at the outset that the specifications have been published as draft, and that NHS England is seeking input/feedback from GPs (and “interested parties”), in the form of a survey (which you can access here).  The deadline for comments is the 15th January.  The final version of the specifications won’t be available until “early 2020”, when the contract for next year has been negotiated with the GPC, at which point we can look forward to “further detail for each requirement, followed by guidance”.

There were rumours circulating before these specifications were published that there would be no additional funding attached to support their delivery, and unfortunately these fears have been realised.  The guidance tries to make as much as it can of the existing funding that has come into general practice through PCNs (the practice funding for engagement, the £1.50 per head, and the funding for the new roles). It also suggests £75M will be available via the Investment and Impact Fund, meaning an “average” PCN could secure c£60,000 in 2020/21 via this route.

The problem is this funding has not felt significant to practices this year, and that is without any additional (unfunded) work being included.  More new roles are available to each PCN next year (with associated funding), but each one comes with its own 30% cost, and it is hard to see practices being motivated to put their hands in their pockets to carry out work on top of the work they already cannot cope with.

In an apparent attempt not to “overburden” the nascent PCNs, only two of the five specifications (medication reviews and enhanced health in care homes) are to be implemented in full next year.  The remaining three will be phased in over the next four years.  It seems there is at least some insight behind the guidance of just how these proposals are likely to land with most GPs.

Perhaps this is all an NHS England negotiating tactic.  Perhaps there is a plan to incite general uproar amongst the GP community, which will be quelled by the inclusion of additional resources at a later date.  The request for feedback and inclusion of a survey on the draft specifications does suggest that at least some parts of NHS England understand the implications of asking these specifications to be delivered unfunded.  However, it is entirely likely that senior parts of NHS England think that this is a reasonable ask of general practice, and so I doubt there is a grand plan or that the final outcome is fixed at this point.

It would be a shame if PCNs, who have come an extremely long way in a very short amount of time, are stopped in their tracks by such short-sightedness.  PCNs represent a major change to the fabric of general practice, and it is one that requires much more nurturing to succeed.  Where we are right now is that they are not at the point of irreversibility, and asking too much in too short a space of time without providing the necessary resources is likely to send many areas right back to the beginning.

But these are not the final versions.  As yet nothing is fixed in stone, and there is a whole round of contract negotiations to go through yet.  My advice to GPs is to send comments in nationally and to your local LMC.  Use the survey, although if doesn’t allow you to say what you want to say send your comments directly to england.networkscontract@nhs.net, and include what is needed to make delivery achievable.  Let’s not give up just yet, and let’s see if something positive can be salvaged out of what is admittedly a less that promising start.

Happy new year to you all!!

Guest Blog – David Cowan – A link worker has arrived. What do I do with them?

A number of new roles have been introduced into primary care over recent years. In this blog, I’ll focus on two ways that social prescribing is delivered, in particular, the active sign-poster referred to here as a care navigator, and the social prescribing link worker.

Care navigators are often primary care reception staff who have received appropriate training on options they can provide patients. The care navigator role should be seen as complimentary to social prescribing when viewed in terms of ‘as well as social prescribing’ not ‘instead of social prescribing’ (NHSE, Social Prescribing and Community Based Support 2019).

The four levels of social prescribing

Social prescribing as care navigation was identified as the first of four levels by Kimberlee (2015), who notes a growing evidence base for providing online information or leaflets in GP practices to help patients choose the most appropriate service.

The key aspect of differentiating the care navigator role, from other types of social prescribing, is the time the care navigator has with the patient. For the care navigator, it’s often a brief intervention with 30 seconds to a couple of minutes for the care navigator to identify the need and, if appropriate, offer the patient a choice between a GP appointment and an alternative healthcare professional.

Kimberlee (2015) goes on to say that ‘social prescribing light’ was the second level, led by the voluntary sector, including providing a point of contact and addressing a specific need, but no direct links with general practice.

‘Social prescribing medium’ is the third level identified by Kimberlee (2015) and includes a health-focused role, with a set number of visits, addressing healthy lifestyle choices through applied behaviour change techniques.

Finally, the fourth level of social prescribing identified by Kimberlee (2015) is ‘social prescribing holistic’ with a direct primary care referral to social prescribing link workers who may be based in general practice, but are employed by a local social prescribing community provider and focus on the persons self-identified needs.

What is the evidence social prescribing works?

Social prescribing can reduce demand for GP appointments.

A recent study published in the BMJ open journal by Kellezi et al (2019), asked 630 patients to complete a survey at the point of referral and again four months after they had received social prescribing.

There was a reported 25% reduction in healthcare appointments and decreased feelings of loneliness.

Dr Chris Dayson from Sheffield Hallam University has contributed towards the evidence base with several evaluations in Yorkshire, such as in Rotherham in 2014, Doncaster in 2016 and Bradford in 2017. These evaluations show a return on investment to the healthcare system, reductions in primary and secondary care demand as well as improvements in individual mental wellbeing scores.

Despite this, social prescribing evaluations often draw criticism for their lack of methodological rigour (Evidence to Inform the Commissioning of Social Prescribing, 2015).

Social prescribing, as signposting or care navigation, builds on the GP receptionist role, who for many years have helped patients choose a doctor or nurse appointment.

As the extended primary care team grows under the NHS Long Term Plan (2019), social prescribing link workers will benefit from spending time with care navigators:

  • By listening to the needs of patients who request GP appointments, they can flag appropriate referrals.
  • Working together GPs, link workers and care navigators can co-develop the systems and processes so that everyone feels confident for direct signposts away from GP appointments to a link worker.
  • There’s also the option of working with a care navigation training providerConexus Healthcare have trained over 10,000 care navigators across England and Wales, with an accredited care navigation training programme. Appropriate training and support is available to social prescribers with the introduction of a level 3 social prescribing qualification.

So, in a nutshell.

Working together, care navigators and link workers are able to play a greater role in helping patients access social prescribing.

So Mr Williams can directly access a social prescribing link worker, via a care navigator, for welfare and benefits advice. Miss Jenkins can feel less anxious about her housing issues because she’s being supported through each step of talking to her housing association. And Mrs Rupinder could wait just days, rather than weeks, to get extra help with her carer duties, thanks to both a care navigator and link worker.

An integrated care navigation and social prescribing service in primary care makes perfect sense. Patients can get the help they need sooner without the need to see a GP first and save finite GP appointments for patients with medical needs.

Dayson, C. (2014) The Social and Economic Impact of Social Prescribing. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact-rotherham.pdf

Dayson, C. (2016) Doncaster Social Prescribing Service. Understanding Outcomes and Impact. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-doncaster-social-prescribing-service.pdf

Dayson, C. (2017) Evaluation of HALE Community Connectors. Available from: https://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/eval-HALE-community-connectors-social-prescribing.pdf

Evidence to Inform the Commissioning of Social Prescribing (2015) University of York. Centre for Reviews and Dissemination. Available from: https://www.york.ac.uk/media/crd/Ev%20briefing_social_prescribing.pdf

Kellezi et al (2019) The social cure of social prescribing: a mixed-methods study on the benefits of social connectedness on quality and effectiveness of care provision. BMJ Open Journal. Available from: https://bmjopen.bmj.com/content/9/11/e033137

Kimberlee, R. (2015) What is social prescribing? Advances in Social Science Research Journal. Vol 2, No 1. Available from: https://blogs.ncvo.org.uk/wp-content/uploads/2016/02/what-is-social-prescibing.pdf

NHS England (2016) High Impact Action Case Study. Available from: https://www.england.nhs.uk/publication/west-wakefield-reception-care-navigation/

NHS England (2019) Social Prescribing and Community Based Support: Summary Guide. Available from: https://www.england.nhs.uk/publication/social-prescribing-and-community-based-support-summary-guide/

NHS England (2019) Long Term Plan. Available from: https://www.longtermplan.nhs.uk/

Lessons for PCNs: Get Some Delivery Capacity

“To me, ideas are worth nothing unless executed. They are just a multiplier. Execution is worth millions.” – Steve Jobs

We could debate whether or not Primary Care Networks are a good idea, but the idea contains enough potential (practices working together, general practice partnering with the wider health and social care system, a focus on the specific needs of a population of c50,000 etc) to state that their success will not be determined by how good the idea of PCNs is, but by how well they are delivered in practice (or “executed” in Steve Jobs parlance).

Lots of people have good ideas.  Some people think their ideas are so good that they pay for a patent on their idea, so that other people can’t steal it.  Forbes reported that, ‘of today’s 2.1 million active patents, 95 percent fail to be licensed or commercialized’.  Most ideas stay as simply that, ideas, and never become a reality because they are never executed.

PCNs are an idea.  At present they exist in the conceptual, and in nascent governance frameworks, but try asking a hospital consultant what a primary care network is.  Their success will not be determined by the size of the population they serve, or whether they have a network agreement in place or have appointed a Clinical Director, but by whether they actually start to deliver and make change happen.  PCNs are still an idea needing to be executed.

Studies into successful change in the NHS have found that there are three critical components of success: clinical leadership, senior support and project management.  Clinical leadership in PCNs comes through the PCN Clinical Director, who has dedicated time to undertake this role (although last week we discussed the importance of protecting this time to make change happen).

Senior support in other organisations of the NHS usually comes from a director who can link the change effort with the organisation’s priorities and the wider senior team.  For PCNs this role can be fulfilled by the PCN Board, who generally have partner level representation from all member practices.

The third component of successful change is dedicated delivery capacity in the form of a project manager.  It is extremely difficult when a PCN CD only has a couple of sessions a week, and practices are working on top of the pressures of the day job, for changes to be made and new ways of working to be introduced.  Change, as we have discussed many times in this blog, is hard, and without dedicated project management it is very difficult to find the capacity to overcome the blocks that will inevitably emerge along the way and make it happen.

While project management for PCNs is not directly funded within the contract, the good news is that PCNs are all being given significant development funding, that will continue over the five years of the contract.  My very strong advice is that PCNs prioritise the use of this funding to establish capacity to deliver change and employ dedicated project management support.

I have met a number of different PCNs on my travels over recent months, and one thing I have noticed is those PCNs who have dedicated delivery capacity in place are the ones who have been able to achieve the most.  The real value of PCNs comes with their ability to execute.  At this point in the development of PCNs, when moving from idea to execution is the critical next step, there can be no higher priority than getting in some dedicated project management support.

Lessons for PCNs: Learning to Say No

“It is only by saying ‘no’ that you can concentrate on the things that are really important.” Steve Jobs

I was talking to a PCN Clinical Director recently, who told me the story of how in one day she had received three emails and numerous phone calls, including to her practice receptionists, for her to say whether or not she was employing a link worker.  She and her practices remain undecided on how to progress with link workers (because they are clear they want the model of social prescribing to drive the employment of the team, not vice versa), but she is coming under increasing pressure to 1) spend more and more time responding to these types of process request and 2) put the needs of the system (and its targets to employ link workers) over the needs of the network.

I was talking to a different PCN Clinical Director who told me that he had received an email with a long list of meetings the system was expecting him to attend.  These included PCN assurance meetings, integrated care development meetings, and a whole raft of clinical “transformation” meetings taking place at the wider system level.  He felt pressure to go to as many of these as he could, and wasn’t sure whether saying no was an option or whether it was a requirement of taking on the new role.

In fact, I am sure it would be relatively straightforward for any PCN Clinical Director to spend all of their time responding to the constant system requests for information, attending system meetings and responding positively to as many of the meeting requests they receive as possible (although I doubt they would be able to meet all of them!).

The irony of this position is that despite this willingness to comply and respond positively, it will be these PCNs who in the medium term will be judged to be failing.

Ultimately, successful PCNs will be the ones who understand their local priorities, focus on building local relationships (between practices and with their local communities), and, most importantly, learn how to make change happen.  All of these things take time, and PCNs who spend their time meeting the requirements of the system will not have the time needed to do the things that are important.

And so the job of the leader, the PCN Clinical Director, is to say no to the things that are less important, in order to be able to say yes to the things that are.

In a recent conversation I had with Professor Becky Malby (a national expert in these matters, do check out her blog if you haven’t already), she recommended that to ensure PCNs focus on the right things they allocate at least 80% of the agenda time in any PCN meeting to innovation, change or improvement, and that the time for everything else should be limited to 20% of the time available.

For the new PCN CDs I was talking to that kind of prioritisation can feel very difficult.  But learning to keep focussed on what is important, and to say no to the things that are not, is critical for PCN success.

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