Why PCNs are difficult – Part 2

In the world of start-ups, the mantra is that any new idea has to solve a problem. Google solved the problem of finding things on the internet, while Amazon solved the problem of buying things on the internet. But start-ups that begin with a solution and search for a problem to solve are the ones that find life much more difficult.

Google Glass is a classic example. It failed because the creators neglected to define what problems it was solving for its users. There was not even a consensus among the creators about what the core use of Google Glass was. One group argued it could be worn all day as a fashionable device while another thought it should be worn for specific utilitarian functions. They assumed the product would sell itself, and that its hype would be enough to appeal to everyone. But in the end, Google Glass did not provide enough advancement for users compared to older technologies (phones), making the product a useless supplement to their daily lives.

There are some interesting parallels between Google Glass and Primary Care Networks (PCNs). There is not a clear consensus as to the core purpose of PCNs. The wider system wants them to be a mechanism through which general practice is “integrated” with the rest of the system, and the GPC want them to be a mechanism for greater investment into general practice. There is an assumption that by channelling resources through PCNs it will make them successful. But in the end, if PCNs do not make a big enough difference to member practices, success is by no means guaranteed.

PCNs need to work hard to avoid being a solution looking for a problem. Because success depends so heavily upon the engagement and participation of member GPs and practices, they have to define themselves early on as the solution to the twin problems of workload and financial viability. These are the problems in general practice that need to be solved, and working at scale, introducing new roles, and working with the rest of the system are proven solutions, and all (potentially) encapsulated by PCNs.

But the reason PCNs are so difficult is that change is not that straightforward. You can’t start with the solution (PCNs) and expect practices to buy in straight away. Changes succeed or fail as a result of understanding the problem, and building confidence that the solution offered can make a difference. If operating at scale was that easy, we wouldn’t still have 7,000 individual GP practices. If introducing new roles was that easy, they would be much more widespread across practices. If working with the rest of the system was that easy, we would have more than a handful of examples of practices working in partnership with acute and community trusts.

The challenge, then, that largely sits with the new PCN Clinical Directors, is to do the work to understand the specific problems facing local practices, and to convince the local GPs that by working with and through the PCN these problems can be tackled. Without this, PCNs risk being a solution looking for a problem, and ending up the same way as Google Glass.

Which is better? A Federation or a Primary Care Network?

The rapid emergence of Primary Care Networks (PCNs) has led practices in many areas to consider the question of whether they are better off as part of a federation, or whether it would simply be better to go it alone as a PCN. So which is better, a PCN or a federation?

What criteria do you use to make this decision? Generally, it comes down to a “what have the Romans ever done for us” consideration. Has the federation/PCN had a beneficial impact on practices? Or does it feel like an entity ploughing its own furrow without really impacting on member practices?

The answers to these questions will vary locally. But the opportunity federations and PCNs can provide for member practices is clear. Federations can provide an organisational structure that PCNs (that are not legal entities) can harness to employ staff, manage risk, and take away any personal or practice liabilities. They can deliver benefits of operating at a greater scale than PCNs, such as attracting higher calibre staff, establishing central functions (such as finance and human resources), and reducing costs through better purchasing power as well as attracting funding for general practice. They operate at a scale where they can build and maintain organisational relationships with all of the local health and social care organisations in way that an individual PCN cannot hope to. General practice itself can have a much stronger voice in the system if the federation is speaking on behalf of all practices, where six PCNs wanting six different things can quickly dilute the collective voice of the profession.

A PCN on the other hand can have a much closer and more intimate relationship with its member practices. It can take time to fully understand the individual challenges each of its practices is facing and take tailored action to support them. It can be nimble and change direction quickly. If the focus needs to change from one challenge to something more pressing it can be reactive and responsive. Each practice can be part of the decision making, and understand exactly what has been decided and why. There can be a transparency about funding, use of resources, and exactly where everything is going. They can make change happen at a local level in a way federations could never hope to, because of the relationships they have in place.

For those of you with longer memories, you may remember back in the days when CCGs were being formed one of the key questions was – what is the right size of the CCG? Should they be small and closer to practices, or should they be large and able to consolidate resources and the available funding to maximise the impact the CCGs could have? In the end both arguments were right: the smaller CCGs didn’t have the resources, influence and financial stability needed to be effective, and the larger CCGs quickly became distant from practices.

The lesson here is that you need both. You need to be large to be effective, and you need to be small to remain relevant to local practices and local populations. The incredible opportunity that general practice has in areas which have federations in place is to have both: they can use the federation to achieve all the benefits that size requires, and the PCN to maintain the localism and energy to drive locally relevant change.

The difficult question, then, is not whether a federation or a PCN is better, but how to bring federations and PCNs together in a way that maintains the trust and confidence of local practices, and allows the two to work effectively together for the benefit of all.

Three top tips for PCN development plans

The development funding available for Primary Care Networks (PCNs) is a tremendous opportunity. But how to make best use of the money? How should PCNs focus their development plans to ensure the money has the maximum impact? This week I consider three ways PCNs can ensure they make the most of the new money.

1.Get Capacity

The one thing that can accelerate the development of a new entity like a PCN more than anything else is capacity. It is virtually impossible for new PCN Clinical Directors to have the time to do everything that is needed to be done in the limited number of sessions they have available. They need someone to be enacting the decisions made, delivering on what has been agreed, and doing the work required to turn ideas into real change. One of the biggest frustrations of the new PCN Clinical Directors is lack of time, and additional capacity in the form of a project manager is the best way of overcoming this.

While some PCNs may be forward thinking enough to invest some of their (recurrent) £1.50 in project management support, many are reluctant to commit what is effectively practice money so quickly. The development fund gives PCNs the opportunity to try a project manager on a fixed-term basis, and then down the line if they find it is a worthwhile investment they can consider making the post permanent using the £1.50.

2.Focus on Delivery

There is something intangible about “development”. But for any new entity (and PCNs are no different) success is dependent upon their ability to deliver. Attending the right meetings, saying the right things to the right people, and learning about how the system works are all well and good, but ultimately if the PCN is not able to deliver anything, it will not be a success. The most important part of development is learning how to deliver.

The best way to learn how to deliver is to deliver something! Don’t think about development as something that is done before you start delivering. Think of it as what you learn while you are trying to deliver. So in the PCN development plan identify what you want to deliver, and make sure you include the resources necessary to make it happen.

3.Create Benefits for Practices

The most important stakeholders in PCNs are the member practices. If the member practices believe in the PCN and its ability to make a difference, then the PCN is much more likely to be successful. Conversely, if practices are working to keep the PCN at arms-length, meaningful change is going to be very difficult to realise.

It is therefore important to demonstrate as early as possible to practices that working together can create significant benefits for the practices and their patients. This is particularly important if the experience to date has been a set of painful meetings to create a network agreement, and then pressure to deliver extended hours. It is perfectly reasonable for the development plan to include work that will not only deliver benefit for member practices, but also include the resources to achieve it.


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.

Page 4 of 38