There is mission creep in every area of the NHS but PCN work is spreading way beyond the original plan of bringing practices together to provide more care locally. Are the new demands now making their mission improbable? Emma Wilkinson reports
Since the ambitions for PCNs were first set out in the NHS long-term plan, the requirements placed on them have been substantial, not least with NHS England’s recent publication of Enhanced Care in Care Homes, bringing a collaborative approach to serve individual needs, in care homes and structured medication reviews.
The pandemic galvanised PCNs to get online services going and provide support at the network level. They then showed just what primary care was capable of by setting up a world-leading Covid-19 vaccination programme at phenomenal speed.
NHS leaders have agreed to hit the pause button on the rollout of further planned specifications, with the BMA saying now is not the time for major contractual changes. Yet there is growing concern among PCNs that they are being asked to take on more and more that they don’t have the capacity, resources or training for.
Dr Sarit Ghosh, clinical director (CD) at Enfield Unity PCN in north London, said once the network DES was in place, everyone suddenly saw the PCNs as the first port of call.
‘For anything that needed primary care input, whether strategy or operations, there was an assumption PCNs would step forward. That put a lot of pressure on CDs,’ he says.
‘When the pandemic happened, people immediately came to the PCNs and CDs to deliver. In an emergency situation everyone stepped up as clinical leaders. But it does show that PCNs are seen as the solution to everything,’ Dr Ghosh adds.
‘Most PCNs are not equipped to deal with a lot of things that are coming their way, but are not in a position to say no either,’ he says.
Dr Colin Garnham, CD at Beverley PCN, one of the largest networks in the East Riding area of Yorkshire, says the Covid-19 vaccine programme shone a spotlight on PCNs. All of a sudden everyone knows they are there.
There is a ‘huge disparity’ between what he expected as a CD and how the role has turned out, he says. They hit the ground running with an incredibly successful programme to have paramedics doing care-home visits but are now struggling to keep up with the demands being placed on them.
‘When the care home DES started, our neighbouring PCN couldn’t cope with all the care homes so we went into an arrangement where we took on an extra two. It’s snowballed to the point where the weak structure of PCN is taking the strain.’
That is in addition to the huge amount of work co-ordinating the vaccination programme including staffing, he adds, explaining that a large amount of his time is spent dealing with bureaucracy.
‘The CCG and the powers-that-be are sending ridiculous emails and requests. I came into this thinking I was a CD and I’d be working with the practices to help direct what we’re going to do with monies, but the CCG seems to think that everything should be sent to us. I spend half my time, if not more, in batting stuff away or dealing with it.’
It is a picture that Dr Geetha Chandrasekaran, CD of North Halifax PCN in West Yorkshire, recognises. Even before the pandemic there was a sense that lots of organisations – CCGs, practices themselves or care homes – saw the PCN as a central place to go to with queries or requests.
‘They do not understand that the PCN is there for some very defined DES stuff. We get quite a lot from CCGs because it is easier for them to deal with five CDs than 20 practices.’
There is a risk, agrees Ruth Rankine, PCN network director at the NHS Confederation, that PCNs will be asked to take on too much and will not be adequately resourced to do it.
‘The Covid vaccination programme has shown that general practice working at scale has significant advantages and that multidisciplinary team working has significant benefits.’
But she adds: ‘There has been an awful lot put onto the leadership of of PCNs during Covid.’
In terms of what PCNs should be doing, a careful balance between national specifications and local flexibility is needed, she says.
‘Our view is that they’ve got the balance wrong at the moment. If you go back to the NHS long-term plan, the purpose of PCNs was to respond to the needs of your population and reduce health inequalities. With the current contract, it’s one size fits all – this is what you will do, irrespective of your population or your demographic, or deprivation levels or your system. We’ve lost the golden thread back to the purpose of PCNs.’
Of course, because this has been such a pressured year for GPs, some new service specifications have been delayed. There is the question of when they will come in, what they will look like and how onerous they will be.
In addition, there are questions about how PCNs will be involved in the integrated care systems (ICS) agenda.
At the moment, Ms Rankine says, some are already involved in system-level discussions and others don’t even know they should be involved, even though PCNs will have an important part to play.
The Government’s white paper on NHS and social care reform after the pandemic, published in February, sets out proposals for ICSs underpinned by legislation that will make ICSs accountable for outcomes of the health of the population.
The white paper alluded to what would be expected of PCNs, but there was not enough detail of how PCNs are involved in system level design, says Dr Ghosh. ‘The ICS white paper underlines that PCNs should have a key role, so there needs to be investment and infrastructure in PCN senior management to be able to do that.
‘The personality of most doctors is to just get on and get things done, but that means running a lot on goodwill. That will run out if people over-commit themselves. If you want a sustainable model, you need to invest.’
Dr Rebecca Rosen, a GP in south east London and a senior fellow at the Nuffield Trust, says an ICS has been operating in her area for more than a year. It sets the strategic plan and PCNs are involved in the implementation.
‘CDs are being drawn into these kinds of developments and they’re having to invest a lot of time, probably more than they ever thought they would have to, as well as being asked to be the voice of general practice,’ she says.
Working to strengthen general practice is already a big ask and CDs are already finding they need more time for that, she adds. ‘If the expectation is that they are going to be the representative of general practice in service redesign and integrated pathways, that is impossible to do on half a day a week. The expectations are growing and growing.’
Within 10 years there is exciting potential for PCNs to do amazing things rooted in the community, but that’s not going to happen within the next year, she says. ‘If you have patience and resources, maybe the expectations are realistic. But as ever in the NHS it becomes about expecting too much too quickly.’
The renewed focus on ICSs could produce a scenario where all these pathways are being redesigned and everyone will be giving tasks to PCNs. ‘Every plan coming out of an ICS will have expectations of PCNs but the ICS leadership will have to be realistic about what PCNs are able to do at the same time as doing the DES. It may be that just doing care homes is enough,’ Dr Rosen says.
There is variation in what PCNs are able to manage. Some have really flourished and others have struggled to get off the ground, says Beccy Baird, senior fellow at the King’s Fund think-tank. There are multiple reasons for this, including whether they were formed from existing networks and what operational and managerial support they have. That is very patchy, says Ms Baird.
In order to carry out population health management, PCNs ‘will need a lot of operational, managerial and analytical support, otherwise there is a limit to what they can do,’ she says.
Dr Farzana Hussain, CD for Newham Central 1 PCN in north-east London and co-chair of the NHS Confederation national CD PCN network, says it is vital to have a network manager. ‘A CD should not be doing lots of management. You are not there to pick up CCG commissioning functions, you are a provider organisation.’
Her PCN had to work quite hard to make that clear when it first set up, she explains. ‘Our network was previously a commissioning cluster and for the first few months we had to be quite strict to say I know we’re the same people, but we’re not commissioning. We’re not here to look at the dashboard. Our job is as a provider – and that is an important distinction. This is about delivery on the ground.
‘A network manager is an essential role, as is having admin support, and that is where a lot of CDs are falling down. I don’t think a network can survive unless they have a manager,’ she says.
Dr Rosen agrees, pointing out that PCNs at the top of their game have this support in place. ‘If you look at the trailblazers, such as Tower Hamlets in east London, they have a manager and somebody providing data analysis and that is what helped them to get off the ground.’
PCNs still need to find their feet, not least to work out how to function together. If they are going to be the voice of primary care at ICS level, that becomes even more vital, says Dr Hussain.
‘Collaborating is easier said than done,’ she says. ‘It’s a different way of working. It requires a big piece of work and that needs to happen now, otherwise they’re not going to be doing anything else.’
She is concerned about the growing pressures on PCNs, especially for winter 2021 ‘because you can only work in crisis mode for so long’.
‘Everyone is going to be tired and there will be a backlog. And we’re looking after all these patients. If I was designing a DES, it would be for the immense deluge of mental health work that will be managed in general practice.’
Some PCN CDs have already increased their role from one to two days a week.
Ms Rankine says that is probably what is needed as a minimum. Coming out of Covid, PCNs will need to take a step back and assess their new baseline. If they’re ‘expected to be all things to all people’ we need to invest in that capability, she says.
Dr Chandrasekaran says her PCN already discusses what work it should and should not be doing at board meetings. They have planned meetings to discuss their priorities after Covid, including what their role with the ICS will be.
‘In April there will need to be a reset and we need to look at what “normal” will be – because we can’t carry on as we are.’
Mission creep is a problem in all parts of the NHS, points out Dr Ghosh, and PCNs are being looked at as a lot of the solution. But actually, he says the solution is to pin down the ICS strategy because the resource then follows.
‘The scope of PCNs needs to be made more clear,’ he says. ‘PCNs have shown they can deliver, now it’s time to really commit to the model. PCNs can deliver with adequate resources.’