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Joining the dots



Despite the lack of detail PCNs are figuring out what will be required of them when the specifications are ramped up in April. Emma Wilkinson reports

Vague, opaque and unclear are the words PCN clinical directors (CDs) use when looking ahead to the coming phase of PCN work. But that hasn’t dampened their enthusiasm for taking this more proactive approach.

April’s new specifications of personalised and anticipatory care – tailoring care around patients and keeping patients well for longer – look to be the two areas that will need the most attention. But at present, CDs feel there is not enough detail to be confident about the current work they are doing. 

Meanwhile, the architecture of the NHS is shifting around PCNs as CCGs disappear and ICS organisations come to the fore.

The workforce is frazzled after delivering the highest ever number of appointments in 2021 and the accelerated booster campaign. And England LMCs are demanding the BMA does not negotiate any new funding for GPs via the PCN DES as it is a ‘failed project… that was mis-sold to general practice’.

It’s not surprising that the focus isn’t on the coming specifications. There is an element of watching and waiting to see if there are further details from NHS England and NHS Improvement, and what integrated care systems (ICSs) will ask of PCNs. 

But that’s not to say work isn’t being done. Link workers and social prescribers are in place. Population health projects are getting off the ground. PCNs are identifying frail patients who would benefit from a more proactive approach. The current challenge lies in identifying the gaps and linking up existing approaches so they are of value, say CDs.

Dr Sarit Ghosh, CD at Enfield Unity PCN says their focus at the moment has to be on recovering services after the pandemic. Demand on practices is through the roof, there are severe workforce shortages, and some aspects of the DES are on the back burner because of the vaccination campaign. Access and long-term conditions are the things weighing on his mind.

‘This is why a lot of the Investment and Impact Fund (IIF) indicators were suspended, because of these challenges. If I’m honest, I think we’re doing a lot of stuff on personalised care and we’re working on anticipatory care through the winter access fund and other areas. Most systems are [looking at this in some form already] because they have to to survive.’

But Dr Ghosh says PCNs are probably not doing anything detailed in these two areas yet. ‘One reason is because it’s so opaque. We’re not sure what the requirements are.’

A lot of this work is incredibly transformational, requiring up-front investment, he says. And on top of that everyone is a bit burnt out. 

It does seem that the DES specifications are not high on anyone’s agenda right now, including health think-tanks such as the Nuffield Trust and Health Foundation, which, when approached for comment, said it had not done work on the anticipatory or personalised care specifications recently.

Sheinaz Stansfield is director of transformation for Birtley, Oxford Terrace PCN in Gateshead, Tyne & Wear. This PCN has been involved in the Year of Care project, which has been instrumental in the development of its personalised care approach.

After identifying a population of ‘frequent fliers’ – those with multiple long-term conditions who were having 20 appointments a year – the PCN offered longer appointments with a practice nurse. ‘We started to do personalised care planning and within six months, patients that used to come in 20 times a year were coming in two times a year,’ said Ms Stansfield.

There is a lot of overlap between anticipatory and personalised care, and practices are doing a lot of this already, she notes. This is not about starting from scratch but ‘joining the dots’. For example, the PCNs have already seen the benefits of having social prescribers and health coaches. 

‘At the moment the system isn’t connected. The anticipatory care guidance gives us that lever to start working with district nurses and with community services on planning and co-ordinating our care.
If someone is frail and housebound, why don’t we have one care plan? Why don’t we have an MDT? Why don’t we connect with local authorities and befriending services to help address isolation?’

Dr Geetha Chandrasekaran, CD at North Halifax PCN in West Yorkshire, points out that as usual the PCN is working without the detail of the specification – and that this hinders any real planning.

But the PCN has had a personalised care team in place for some time, and is starting by trying to unpick the reasons why referrals slumped during the pandemic. It is also doing a lot of work on inequalities. Dr Chandrasekaran also wants to achieve greater co-ordination of all the different strands.

‘The team is growing,’ she says. ‘We have social prescribers, our care co-ordinators, and we now have a health and wellbeing coach in our PCN. We have put them all together. In Calderdale we have a PCN that’s got a frailty nurse and an occupational therapist and that’s soon going to be extrapolated across the region because we’ve identified that it works for people. And we’re doing some other work on anticipatory care.’

While she says it’s ‘all gone a bit pear shaped’ during Covid, ‘getting to the proactive’ bit has always been at the heart of primary care. Her goal is not just identifying the groups of patients who would benefit, but making all the different pathways robust enough to manage them, whether they need end-of-life care, or help with frailty or other issues, perhaps mental health. The PCN is also working to get the team based in a hub so there can be real connections with colleagues.

All this will, of course, require training of staff, which they are looking at doing at a place level.

‘We have to recognise if we do this, we have fewer acute admissions, fewer falls, fewer urgent calls out to practices, and fewer contacts because we’re proactive. The downside is it takes time to recruit [these hub roles]. It takes time to train them and we don’t have a structure for training,’ she adds. 

Dr Chandrasekaran’s main concern is that the PCN will start doing a piece of work one way, then end up doing it another, just to tick the boxes. ‘It is very vague,’ she says. ‘They’ve left it very open. I’m wondering whether they will [concentrate on] planning rather than doing this year – that’s hopefully where they’ll go with it.’ 

Professor Chris Drinkwater, emeritus professor of primary care development at Northumbria University, has been at the vanguard of work in social prescribing. He is one of the founders of the Ways to Wellness service in Newcastle. He agrees PCNs are in a really difficult position at the moment, and his advice is to look carefully at the groups where you can have the greatest impact.

‘It might vary between different areas and different practices,’ he says. ‘If you’ve got a largely older population, you might want to look at frail older people and dementia. If you’ve got a younger population or a BAME population, you might want to look at type two diabetes and obesity.’

And Professor Drinkwater advises trying to pull together a project on personalisation and anticipatory care ‘because there’s a danger that you end up with segmentation and lots of little projects [that] become very difficult to manage, and don’t necessarily achieve much’.

Through his work he has found the key to effectiveness is building trusted relationships – something that does not necessarily fit into a tick-box exercise and is a long-term proposition.

‘The link worker is the intervention rather than the activities because it’s about building trusted relationships with often very vulnerable people who, particularly in disadvantaged areas, can be distrustful of authority figures. This is one of reasons why I think PCNs in disadvantaged areas should have a larger number of link workers.’ 

Signposting to services is not enough, he adds, and the social prescribing role should not become about form filling and data collection. ‘You can tell people about services but the more vulnerable they are, the more disadvantage they know, the less likely they are to go along to those services.’

Larwood and Bawtry PCN in Nottinghamshire is hoping to build on a model of anticipatory care it has had in place for some time.

Dr Richard Davey, who recently stepped down as CD, says: ‘From our perspective, what good looks like is a diarised meeting that happens regularly with admin support and people buy into it because it works.’ This MDT meeting – there is one for palliative care and one for frailty – is attended by the PCN clinical pharmacist, social prescribers, paramedics, care co-ordinators and community teams as well as the GP.

‘Hopefully, for us [meeting the DES requirements] should be seamless, but other PCNs that are still relatively immature or [struggling] to recruit into these roles [may have]problems to meet these targets.’

He adds: ‘Most individual practices have some form of frailty and palliative care structure but how will that be linked on a PCN footprint? I think that’s more challenging for the bigger multi-practice PCNs.’

The focus for practices will largely depend on the agenda set by the ICS, he notes, but there is potentially a lot of scope for reducing inefficiencies in the system. ‘I’m hoping there’ll be a lot of latitude in how they monitor this and how they sign off for payments so that people engage with it appropriately, because the more rigid and dictatorial it becomes, the less people will engage with it.’ 

In West Devon the PCN commissioned the first locally enhanced service for population health management in older people last year. Dr David Attwood, a GP and CCG clinical lead for integrated care and older people, says it is based on the premise of segmenting the over-65s, grading them from no frailty to severe frailty and looking at the evidence-based interventions that work in each group. Six out of nine PCNs are now signed up to the fully commissioned service, he says.

For moderate and severe frailty, an MDT of the community services team and a GP do comprehensive geriatric assessments, which includes a medicines review. The service funds the GP time. Dr Attwood says: ‘We’ve also arranged the system so that each PCN has funded time put aside for a GP to be able to work alongside this MDT and each PCN is also funded for a complex care clinic for older people.’

‘It seems to be working really well and the feedback I’m getting from people on the ground is that they feel like they’re making a difference to patients.’

This approach might not work for everyone, he admits. ‘We’re in one of the most socially deprived areas of the country and this is the way we’ve done it, we’ve built a model around enhanced primary care.’ 

Other places might have a central hub area you can refer patients to, he says. ‘My key message is for each area to look at its assets and try to find solutions that will work best there – identify the population group, segment that population and look at the evidence-based interventions for each.’

His PCN did have to consider a model that was ‘flexible and scalable’ because it was not flush with staff. ‘We suspect that some practices may struggle with physical bodies to deliver on this. That has been the challenge for the other three networks as they said they really wanted to do it but didn’t have the staff. I suspect that is going to be a problem nationally.’

There are things that will need to happen at the ICS level – not least working out how everyone locally can use the same care plans, says Ms Stansfield. ‘For anticipatory care to work we need standardised processes that everybody understands and everybody’s bought into. Then you need the same training across the board. There are so many variations of what personalised care planning is, so we need to choose which one will work for us and use it across our system. And the ICS really needs to support that; that will be crucial.’ 

Having data on population health is one thing, but the pandemic has added another factor. There are patients who have been shut in their houses throughout, with the isolation, physical and cognitive decline that goes along with that.

‘It’s a tsunami,’ says Ms Stansfield. ‘When we open that door, we will be flooded by it. When Covid began we sent out our practice nurses to see housebound patients, and we’ve found so much unmet need.’ 

She is planning to start tackling this by building on connections created during the pandemic with local authorities, community teams and the voluntary sector. ‘We need to connect, we need to develop relationships, have time to talk to each other. We need to develop trust and collaboration.’ 

She adds: ‘For the past 18 months, CDs have been outward looking on vaccination. Now they have to be inward looking and if they aren’t that’s a massive risk because PCNs are imploding because practices are imploding and there is no trust. It’s essential that they go and talk to the practices and [help them] to understand what this means and how they have to engage.’