As the changes in the upcoming Health and Care Bill filter through the NHS, PCNs ready themselves to ensure they have a strong collective voice and can seize the opportunity to shape care for their populations by engaging with integrated care systems (ICSs). Emma Wilkinson reports
In less than a year, 42 ICSs will be fully formed legislative bodies tasked with helping NHS and social care sectors across England to ‘connect, communicate and collaborate’. Each will comprise an ICS NHS body, responsible for the day-to-day running, and an ICS health and care partnership, bringing the NHS, local government and the third sector together to improve health and wellbeing outcomes for their population.
PCNs will have a seat at the table, but maybe no more than that. The ICS: Design Framework, published in June, calls for one GP provider to sit on the board as part of a core team of around 10, including one representative from social care and NHS trusts. All three of these ‘partner members’ are expected to be ‘full members of the unitary board’ but not act as ‘delegates’ of their sectors.
However, NHS England says that it expects every ICS board to establish roles ‘above’ the minimum level in order to ‘carry out its functions effectively’.
And many ICSs are already starting those discussions about representation. Dr Minesh Patel, chair of the National Association for Primary Care (NAPC), says the relationship needs to be strong but will not be built overnight.
‘PCNs and the ICSs in which they now operate are both very immature structures. We know that from other parts of the world where perhaps the integration of care has been more advanced, that journey takes 10-20 years, perhaps even longer,’ he says.
A unified local voice
Local relationships will provide the foundation of the ICS but there is no doubt this is a tough ask for PCN clinical directors who are also trying to build relationships within their network while the system develops around them, having just been through an extremely testing pandemic period, he adds.
‘I think it is a tremendous challenge. I don’t envy them. I don’t think they’ve necessarily been given the resources required to do that.’ And he says it should be remembered that the framework that will be in place in a year’s time will not be the finished product.
One key question for PCNs is how to organise themselves to provide a unified voice at the scale of the ICS. Dr Tom Holdsworth, clinical director at the Townships PCN in Sheffield, South Yorkshire, has recently started working on this very problem.
‘There’s keenness and willingness but the relationship at the moment is in the early stages,’ says Dr Holdsworth, who has been given protected time by the CCG to understand not only the ‘nitty gritty’ about who’s on what committee but also how information and communication will move up and down the layers.
‘One of the strengths of Sheffield is that the PCNs have quite a developed relationship so there are quite high levels of trust and understanding between the network directors,’ he says. But he adds that there will need to be governance, although not overly bureaucratic.
‘When things are all going smoothly, it’s the relationships that carry you along and allow you to work effectively. If things get difficult, or you know there will be times when you don’t all agree completely, that’s when you need some governance to fall back on.’
The challenge for PCNs, he adds, is that in some ways they’re at their most effective when engaged in local work but now the system is asking them to shift their perspective. ‘How you manage that it is partly about the trust and the relationship, so we don’t all have to do everything and be in every meeting. If we have the governance structures to facilitate that, then we can make it less burdensome for practices.’
Forming an alliance
In Dorset, one of the smaller ICS regions with a population of about 800,000 and 18 PCNs across two local authorities, the plan is for PCN representatives to sit on two health and wellbeing boards in the local authority ‘places’ as well being on the ICS statutory board.
Dr Simone Yule, GP and clinical director of the Vale PCN in North Dorset, says when it comes to representing 79 practices at a board level, the current thinking is to have some form of primary care alliance.
‘It’s really important that whatever form you take as PCNs, it’s an agreed form. So if it’s an alliance with terms of reference, you have a mechanism for giving the people that sit on the ICS board the mandate to be your voice. We have to agree that and it has to be recognised that that voice is in the greater interest of the PCN as a whole.’
In terms of primary care representation in the important ICS work streams, business managers, practice managers, nurse practitioners and other parts of the wider primary care team should also be involved, she says. ‘We are a key player here and we’ve never had the opportunity really to be a key player.’
Dorset ICS lead Tim Goodson says collaboration is always far more difficult than competition because it involves trying to get people to support decisions that are not necessarily in their best interests. ‘And if you’ve got a couple of PCNs represented, they’ve got to go back and explain to the rest of their colleagues. That communication
on some of the decisions I think can be difficult, not just for PCNs but for any partner.’
Yet he sees no reason, with investment in time and support, why PCNs shouldn’t be able to provide that unified voice. The most important bit to get right is the ability to do things at different levels – place, PCN or practice level, and not always at the top.
‘I don’t want to get bogged down in whether we do this at this level or this level. We need to take the right decision at the right step,’ he adds.
Working with neighbourhoods
The ICS in West Yorkshire, which covers five local authorities with 52 PCNs and six acute trusts, is also building on relationships that were in place before PCNs were formed. The key principle they are working from is subsidiarity – dealing with an issue as close to the person as possible, explains ICS lead Rob Webster.
‘We’ve adopted the subsidiarity principle that starts with the practice unit – strong primary care with a strong PCN in a strong system. It’s important to get this right.’
The ICS is working with the concept of neighbourhoods – essentially PCNs – within five local authority ‘places’. While most of the ‘work’ happens at neighbourhood or place level, when decisions are needed at a West Yorkshire level – such as on mental health or health inequalities – PCNs will have input, he says.
‘As we move towards statutory basis, we’re looking at the role of the CDs within a PCN, and how they are represented at that senior level. We’re setting up a CDs’ forum for the 52 PCNs and appointing a clinical lead to support our approach,’ he adds.
His understanding of the white paper and draft legislation is that it will be clear about the statutory role and functions of an ICS body, but will not be prescriptive about the governance in a place. Local models are being proposed – which relates to the maturity of the networks, he says.
He echoes the view from Dorset that not everything should happen at an ICS level and he doesn’t expect the PCNs to solve the problems of the whole area. What is essential is that they can operate effectively at the ICS, PCN and local place level.
Report on the role of primary care
The NHS Confederation, which represents NHS organisations including PCNs, published a report at the end of May looking at the issue of primary care engagement at system level.
The Role Of Primary Care In Integrated Care Systems calls for clarity to prevent a ‘tokenistic offer’. The report, which involves a survey of more than 200 primary care leaders including PCN CDs and managers, highlights concerns that primary care is not being sufficiently engaged with or involved in ICS decision-making.
Only 12% of primary care leaders who responded said they were always involved in discussions at system level and 50% stated that they were ‘unclear’ or ‘very unclear’ about the role of primary care networks in ICSs.
The report sets out five key requirements reflecting its members’ views on what should be included in the development of ICS structures, governance and culture:
- Collective voice and representation for primary care at system level.
- Processes and structures for primary care at place level.
- System priorities that reflect local neighbourhood needs.
- Systems that promote collaboration.
- Enablers – investment in primary care leadership capacity and capability and financial certainty.
The larger ICSs arguably have a harder job in creating a truly integrated system, not least because they are working across boundaries that people rarely travel across for healthcare.
In Cheshire and Merseyside, the current leaders, Jackie Bene and Alan Yates, recently announced their intention to quit because the task had become ‘significantly different’.
Ms Bene, chief officer at Cheshire and Merseyside ICS, which covers a population of 2.6 million, confirmed to Pulse PCN that she would not continue in her role after April 2022. She described the relationship between the 57 PCNs and the ICS as very good and improving.
A new primary care provider leadership forum includes a PCN CD from each of the nine ‘places’ in the system as well as LMC and GP Federation members. In what she describes as a ‘significant step’, two members of the forum will be elected to sit on the partnership board. Further down the ladder, PCN forums have been created in most of the nine localities.
‘We believe that the structures we have put in place provide a democratic and transparent process for the primary care voice to be heard at ICS level,’ she says.
Dr Dan Bunstone, clinical director of Warrington Innovation Network PCN in Cheshire, says PCNs are ready and waiting to be involved with the ICS but it will not be an easy task. ‘The local variation and control is going to be tricky as the regions coalesce. The sheer change in size is huge and the timing short, as PCNs are still in the developing stage after Covid.’
There also needs to be flexibility in where decisions are made, he adds. ‘We need to return to the localism of PCNs. Our job is to deliver strategies fed down from the ICS and I’m not sure how that will work.’
The resignation of the current leadership is a fairly seismic move, he says. ‘We are at a critical point in the development of Cheshire and Merseyside ICS, so to lose two very experienced and respected leaders who have been deeply embedded will cause ripples and concerns.’
Dr Paul Bowen, medical director at the Middlewood Partnership in East Cheshire, agrees that it is daunting to lose a leadership that inspired confidence in the task of transformation just nine months before ICSs become statutory bodies in April 2022, subject to the passage of the health and care bill through parliament. ‘It is a concern that we are losing, late in the day, two supporters of localism and pragmatism.’
In his view, there was not enough focus in the ICS white paper on the potential of PCNs, which leaves ICSs to ensure primary care is properly embedded. Yet at the moment, the focus is either on recovery from the pandemic or reorganisation.
‘It would have been better to have an intermediate step for a year or two. Providers should be focused on restoring normal NHS work at this time and it’s a lot to ask of people who are pretty exhausted.’
Dr Patel says it is realistic to set up the basic framework for next April, but they also have to create the space for people to collaborate differently. ‘Representation is not the answer alone,’ he says. ‘We need representation with a depth of engagement. A lot of developments happen just because people are able to communicate with each other. How do we generate a system with a space, and the resource to make that happen?’