In this feature Thoreya Swage, Healthcare Consultant, provides an update on the establishment of Primary Care Networks in England and describes the resources that have been made available to support their development.
In January 2019 NHS England published the NHS long-term plan for England. A key aspect of the plan was the development of Integrated Care Systems (ICSs) across the country together with extra funding for primary and community services. This funding would be channelled through Primary Care Networks (PCNs), groups of neighbouring practices of about 30,000 to 50,000 population in size, to enhance primary care services. Some PCNs are, in practice, joining together to become larger groupings with smaller constituent PCNs led by a single shared Clinical Director. There are 1,259 PCNs in England.
Update on Primary Care Networks
PCNs were negotiated as part of the GP contract published at the same time as the NHS long-term plan in January 2019. PCNs are supported by network contracts in addition to the core GP contracts held by the individual practices and they were established in July 2019. PCNs are led by Clinical Directors who are appointed or elected by the constituent practices. A Clinical Director does not have to be a GP as PCNs are set up to develop multi-disciplinary working and to grow other clinical staff, e.g. nurses pharmacists, allied health professionals etc in primary care. Clinical Directors can job share between two or more people.
What do PCN Clinical Directors do?
Essentially PCN Clinical Directors (CDs) provide the leadership for the strategic aims of the network, working closely with PCN GP practice members to deliver the improvements in the quality, cost and effectiveness of the services that are provided.
PCNs, as groups of collaborating practices, will have a designated single bank account through which all the network funding flows.
Support to Clinical Directors
As these are new and essential roles, a key task for STPs/ICSs is to formulate a leadership development programme for the Clinical Directors within their PCNs. The programme is expected to focus on personal development of the CD and to help them establish and provide leadership to a PCN and within the system.
The leadership development programme should cover a range of areas including managing change, using data and information to facilitate clinical decision making, managing the finances, developing a team and the wider workforce, influencing and engaging staff and other stakeholders and involving the public.
The CD leadership skills to be honed are being able to present a vision, establishing relationships, understanding the local community and engaging the voice of local citizens.
Ambitions and expectations for PCNs
By March 2020 it is anticipated that PCNs will:
have identified where they wish to get to over the next five years, by using a diagnostic method such as a maturity matrix or similar to clarify their development need and to establish a development plan
have matured in the way they are functioning as a cohesive team
be working as part of a network of PCNs within the ICS/STP plan to deliver the NHS Long-term Plan
have established multi-disciplinary teams with local community providers
have strengthened links between local community people and groups to understand how to deliver care most effectively for patients and their populations
be working through with community partners their estate requirements in the future
have started on at least one service improvement project that is linked to the Long-term Plan goals
have utilised in full the funding for additional roles as described in the national guidance.
In the immediate future PCNS have been asked to focus on three main areas which are:
improving access – for example PCNs could help with improving the organisation of practices and their systems to facilitate patient access to appointments at their surgery
workforce pressures – organising and accelerating the use of other primary care professionals such as pharmacists, physiotherapists and so on across more than one practice to support the core primary care staff
linking up primary and community nursing – there are about 1,200 PCNs across the country covering populations of between 30,000 – 50,000. This is localised enough to enable primary and community teams to work together to assess and treat their patients in a cohesive and joined up manner.
Over the next five years NHS England is expecting PCNs to have achieved five things including:
stabilising the GP partnership model
enhancing the skill- mix and the gap in the workforce capacity by adding extra (over 20,000) staff in the primary care setting, as well as increasing GP and practice nurse numbers
demonstrating that they are a robust platform for continuing local NHS investment
integrating primary and community care such that both sectors look to each other to work together
delivering new services in accordance with the Long-term Plan, including the seven new service specifications as well as achieving clear impacts for people and patients.
Delivering sustainable transformational change
Transformation in the delivery of care between organisations is best achieved by the teams that are driving this change themselves; for their local services and populations. This bottom up approach is vital to the success of PCNs in their development and sustainability.
At the same time, it is not effective for PCNs to come up with their own answers to problems that are common to a number of network groups. Therefore, it is anticipated that PCNs use or adapt standard methods on various issues, such as medicine management or support to care homes, where this makes sense.
There are three characteristics that are essential to delivering transformational change that is sustainable which are, that they are:
owned and delivered by teams
concentrated on enhancing care for people locally
underpinned by a clear sense of purpose.
Sustainable change can be supported by the NHS change model which was developed originally in 2012 to facilitate joint working between health and care in developing a shared vision for leading transformation. This model provides a framework for any project which is seeking transformational and sustainable change. The approach contains prompts, ideas and tools which can be used for each situation and can be used for a wide range of circumstances from a small organisation to the whole system.
At the centre of the process is the shared vision which is supported by eight elements which are key when implementing change. These include leadership, spreading and adoption of ideas, tools to use for improvement, managing the project, measuring progress of the project, main drivers of the system and motivating and mobilising people for change. For success, establishing the shared vision is essential to obtaining the change.
PCN Maturity Matrix
Like most processes before, the NHS measures the development of new organisations and structures through the use of a maturity matrix. NHS England has developed one such matrix to assess the development of PCNs although many have already developed their own.
Essentially the matrix charts the journey a PCN travels along from the initial steps taken to establish itself and deliver changes locally through to wider working across PCNs and ICSs/STPs.
PCNs across the country are at different stages of development and the ones that are more mature will have been working closely with other partners for some time. It is essential that existing good local working relationships and ways of working are retained while PCNs continue their development. It is also important that current improvements that will have been facilitated by the GP Forward View and other local projects that support integration are recognised and built on.
The PCN matrix is designed to facilitate discussions between PCNs and their ICSs/STPs and to chart a multi-year journey, building on current progress that has taken place to transform and enhance care for patients and populations. Work with some ICSs have shown that the development is most fruitful when the groups of practices in a network come together with their CCGs and other local providers, e.g. community services and local authorities and so on, and having a joint discussion on progress to identify future plans for integrated care and any associated support to enable PCN development.
The PCN maturity matrix is flexible and will change as PCNs develop. It is therefore anticipated that, for example, some areas that are covered by the 2019-2020 support domains within the matrix may in the following year become part of the PCN service specifications. Draft and final service specifications should by considered by PCNs and their systems so that these can form part of future support requirements.
Support to PCNs
It is expected that the support provided to PCNs will be twofold; a) for development of the PCN itself; and b) for the development of PCN Clinical Directors. There are six steps to put into place for PCN development support including:
Establishing the PCN – this includes identifying the membership, appointing the Clinical Director, signing the Network Contract DES requirements and seeking the wider members of the PCN and partner organisations
Setting the vision for the PCN – this involves the STP/ICS and other organisations facilitating discussions with PCNs to enable them to identify their vision and areas of focus. Each PCN is to identify a specific service improvement priority to develop in closer collaboration with other partners, e.g. community and mental health services, social care and other community organisations
What help is required? – this means agreement of specific development needs for 2019-20 with a view to further development needs identified for 2020-21.
Who can provide the help? – The ICS/STP can use the PCN Development Support funding to implement the agreed programme for development for the PCN and partners. However, existing support funds are to be used before the additional PCN Development Support funding is taken up.
Implementation – support is provided and implementation of PCN development is underway
Are the PCN goals being achieved? – this is the final step of the journey when progress is reviewed against the PCN priorities. This is the time when additional areas requiring support are identified and the learning is shared.
There are various tools, for example the PCN maturity matrix and PCN self-assessment tool, and the NHS change model to facilitate PCN development.
Funding for support to PCNs
NHS England has made available £43.5 million via ICSs and STPs to support the development of PCNs in 2019-2020. There is an expectation that CCGs will add extra support over and above the national funding as some have already done so.
It is expected that the national funding should be used for PCN development and a specific Clinical Director Development Programme is agreed in each STP/ICS. The aim is to facilitate the progress of PCNs in achieving their objectives.
Below is a list of what the funding support for PCNs can and cannot be used for:
What the funding can be used for
What the funding cannot be used for
The timetable for PCN and Clinical Director development is challenging however, in many areas much work has already taken place owing to pre-existing mature relationships between health and social care partners.
PCN Development and Support – Guidance and Prospectus, NHS England and NHS improvement, August 2019
The Primary Care Network Handbook, British Medical Association, 2019