18
dec
0

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

Posted by Blogs, The General Practice BlogNo Comments

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/

11
dec
0

Lessons for PCNs: Get Some Delivery Capacity

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“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.

4
dec
0

Lessons for PCNs: Learning to Say No

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“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.

27
nov
0

The future for GP Home Visiting Services?

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The national LMC conference caused a stir in the national press last week when they passed a motion instructing the GPC to negotiate the removal of home visits from the core contract.

Hardly surprising given the timing and the forthcoming election, with each of the main parties falling over themselves to say how many extra GPs they are going to train and recruit should they be elected (Conservatives an extra 6,000 GPs, Labour and Lib Dems an extra 5,000 GP training places).  And of course it was easy for the press to sensationalise the story as an “end to home visits”, and for Matt Hancock to reject that notion out of hand, when that was not what the conference voted for.

So what did they vote for?  The specific motion was:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

  1. Remove the anachronism of home visits from core contract work (passed 54%-46%)
  2. Negotiate a separate acute service for urgent visits (passed 74% to 26%)
  • Demand any change in service is widely advertised to patients (passed 90% to 10%)

Let’s be clear, the motion was not really about the merits or otherwise of home visits.  It was about GP resourcing and workload.  Despite the existing promise of 5,000 more GPs, the number of GPs has gone down while the workload has continued to rise, at a rate exceeding any increase in funding.  And so, inevitably, we end up with motions like this, which are statements that the current situation is unsustainable.

Something needs to be done.  I don’t think many of those at the conference believed the GPC would be able to negotiate such change to the contract, but rather they wanted a line drawn in the sand.

If the contract itself isn’t going to change, what can be done, and can the visiting system be changed to reduce pressure on GPs?

It is interesting that the level of support at the conference was so high (74%) for the introduction of a separate service for urgent visits.  Whilst some portray the debate as one of access versus continuity, this is snot necessarily the case.  Most current visits by a practice will not necessarily be by the patient’s own GP.  There are systems that have developed in different places around the country where a paramedic or nurse practitioner report back into the surgery before, during and/or after carrying out a home visit.  It does seem there is mileage in such a system that could potentially (according to the LMC conference debate) release 2 hours a day of time for practices.

Of course, not all visits are equal.  Many GPs in the debate have drawn the distinction between urgent on the day visits particularly requiring a “convey to hospital or not” decision, and the scheduled complex visits for very frail elderly people, those with severe disabilities, and those at end of life.  An acute visiting service would be for the former of these types of visits only.

What interests me is why practices are not planning to use the new roles coming via the PCN contract to set up such a service.  The LMC conference gave its own verdict on PCNs, passing a motion that PCNs would not reduce GP workload and would not address the workforce crisis.  But if practices chose to use the new PCN roles in the way they are asking for in relation to visits, it does seem as if PCNs could have an impact.

If the conference had slightly amended its motion as follows, NHS England may have potentially been more receptive:

That conference believes that GPs no longer have the capacity to offer home visits and instruct the GPC England to:

  1. Shift the requirement of home visits from core contract work to the PCN contract
  2. Negotiate sufficient resources for PCNs to establish an acute service for urgent visits
  • Demand any change in service is widely advertised to patients

Would this, though, have garnered the same media reaction?  Would it have drawn the line in the sand that the LMCs were seeking?  Unlikely.

But do practices within a PCN require such a motion to be passed?  What is stopping them from deciding for themselves that this is how they are going to use the new roles that are being funded within their PCN?  I doubt local commissioners would get in their way.  Indeed, I suspect such an initiative would be welcomed, and could even attract additional local resource.  The bigger barriers are internal: the change capacity within PCNs; and of actually making change happen across multiple practices.

Relying on the promises of the major political parties to resolve the challenges in general practices is unlikely to be any more successful in the future than it has been in the past.  Whatever the right changes to make are, the best ones are going to come from within the service itself.  If 74% of an LMC conference believe an acute visiting service will help, maybe now is the time to push ahead with its implementation.

19
nov
0

A Network of Primary Care Networks?

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Is a network of primary care networks (PCNs) a good idea?  What are the benefits, and why is operating a network of PCNs more difficult than it might at first appear?

It is only a couple of months ago that practices divided themselves into groupings along PCN lines, and the scars in some areas are not yet fully healed.  So it is with understandable trepidation that some PCN Clinical Directors are thinking about whether operating as part of a network of PCNs is something they really want to be part of.

The rationale for PCNs to work together is fairly solid.  There are (at least) four good reasons to do it.  First is simply for support.  PCNs are new entities, and many Clinical Directors (CDs) are new to such a leadership position.  By working closely with other PCN CDs, they can make sure they understand what is required of them, how (and whether) to meet the various asks the system is putting on them, and can share intelligence as to how to meet the different PCN requirements.  There is a safety and security in numbers, and operating together reduces the risk of your PCN becoming isolated, of making unintentional errors, or of being singled out by the system.

Second, working together as network of PCNs creates a greater capacity to meet the ever-growing demands the system is placing on this new cadre of leaders.  If one PCN CD can attend a meeting instead of five, the collective group of PCN CDs is better able to manage the workload between them, and protect precious time for building relationships between practices within the PCN.

Third, the collective voice of all the PCNs in an area speaking together is much more powerful than that of any individual PCN.  Indeed, if one PCN says one thing and then is directly contradicted by another, the overall voice of local general practice is weakened and the potential influence of the new PCNs hugely reduced.  But if a network of PCNs can agree a position, it can be hugely influential on the CCG and wider system.

Finally, the level of resources provided to PCNs is small compared to the asks that are being made of them.  By sharing resources, e.g. administration, finance, recruitment, training, HR (etc), the PCN pound will stretch much further, and the benefit to practices and ability to deliver significantly increased.

If the benefits are so clear why, then, is not every PCN already operating within a network of PCNs?  Indeed, why is it that in some places where such alliances across localities previously existed, they have they fallen by the wayside with the advent of PCNs as more formal entities?

Essentially, it is a question of trust.  For example:

  • Do I trust the other PCN CD to speak on my behalf and adequately represent my PCN?
  • Do I trust the other PCN CD not to take advantage of any opportunities for their own PCN, before sharing any relevant information with me?
  • Do I trust that the decisions the other PCN CDs will make are the best ones for practices? Or that if I make a decision that is worse for my PCN but better for the wider group, when the scenario is reversed the other PCN CDs will equally make the same decision?
  • Do my practices trust me to make the right decisions when it comes to the other PCNs? Will they back me if I choose for us to be represented by a different PCN CD? Isn’t it safer to make sure I represent my practices directly?
  • Do I trust that I am getting a fair share of resources that are shared?

With sharing comes a loss of control.  Giving up control in this way requires trust.  The benefits of PCNs working together in a network of networks may be obvious, but without trust it is very difficult for them to be realised.

 

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