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PCNs have been asked to change focus following the update to the Network DES. In the second of two features, Emma Wilkinson looks at how PCNs are coping with constant change. You can read the first feature here.
PCNs had just emerged from a long winter of extreme pressure on the NHS when the update to the GP contract in England was published. They had also spent the past 12 months focused on the impact and investment fund (IIF). And then they were asked to switch their focus – again.
Now, they must think about how to improve patient access and show that they are making the patient experience more positive. But there is the view – and not an uncommon one – that PCNs have been asked to address access in a way that is political rather than evidence-based.
Dr Nicky Turner, clinical director at Chalfonts PCN in Buckinghamshire, says the reality is far more complex than just a few appointments. She notes that there is a limit to what is within PCN control, especially given secondary care waiting lists that create more pressure on general practice.
One thing they have done locally with Berks, Bucks and Oxon LMCs is to introduce the General Practice Alert State (GPAS) system, which provides dashboard data equivalent to hospital Operational Pressures Escalation Levels (OPEL) ratings. She hopes it will help them build a picture of what is happening.
They are already using total triage, which works well for them, but other practices in the PCN use different approaches, including AskmyGP. But they are introducing a system called EDATT: Enabling Digital Access Through Telephony.
The patient experience
This ties in with the Fuller Stocktake, which found that practices must improve experience, access and outcomes alongside improving the digital literacy of patients and the public.
EDATT is a Chatbot that uses existing practice systems and (if the patient accepts it) takes the patient through how to sign up to and use digital services. Dr Turner says they are also doing some work through adult education and literacy sessions.
‘We’re still finding people phoning for results and so on, so this will hopefully help to encourage them to use the app as well as helping them to access it,’ she says.
But, she adds, beyond this, there is a limit. They are desperately trying to recruit after two brilliant physician associates returned to the United States. Until the switch to access, they had been all set to carry on with progress they had been making on IIF work.
There is a big cardiovascular plan involving practice pharmacists that will likely continue. But other things they wanted to do in the last year of the contract – around things like green inhalers, for example – will now fall by the wayside.
‘We haven’t got the capacity to do that now. It is quite tricky when everything keeps changing so quickly, and it is unsettling for some staff in the practice because they don’t know what’s happening from one year to the next,’ says Dr Turner.
The wrong focus?
All this comes from the assumption that more appointments equals better healthcare and better satisfaction with general practice. But the data shows that is not the case.
Dr Nicholas Jackson, clinical director at Selby PCN, agrees that access is the wrong thing to incentivise when the evidence points to continuity of care being the most important factor.
In 2018, Professor Sir Denis Pereira Gray published a paper showing that continuity in general practice was associated with lower mortality. This was backed up last year by Norwegian research, which also showed continuity was linked to lower use of out-of-hours services and fewer acute hospital admissions. The Future of General Practice report from the Health and Social Care Select Committee enquiry agreed and called for a national measure of continuity.
Dr Jackson says: ‘Focusing on access really misses the point about what the evidence is saying around what quality care looks like because all the evidence is around continuity of care.
‘If we were being incentivised to improve that, then I think that would be a really good thing and something that general practice could get behind, but just being told – encouraged, coerced – to get more and more appointments, I think, is the wrong thing to do.’
Continuity of care
The inverse care law suggests you provide more access for those who do not need it the most, says Dr Jackson.
‘I would want to be building into our improved access improvement plan something around continuity of care or something that tries to target the people most in need, whether that’s frequent attenders or underserved populations.’
He does not know whether that will get past the ICB. And if not, Dr Jackson says he ‘would not be interested in chasing that 30%’. That’s despite having data and cloud-based telephony in place.
‘It’s not enough because we’re trying to deliver more and more with a diminishing workforce, and ARRS roles do not really fill that gap. There’s no evidence that I’m aware of that says waiting three weeks for a GP appointment is worse than waiting two if it’s the right person for the right condition – in other words, continuity of care,’ he says.
Their focus now, as it has been for the past year, is a massive recruitment drive to use their quarter of a million-pound underspend on ARRS to secure future funding and to do it in line with their priorities. Not an easy ask.
But knowing that every practice’s pressure point is same-day urgent care, they have plans to put some resources into a ‘Fuller-type urgent care hub’ to try and develop a combined solution run out of a local community hospital. Dr Jackson says that, despite seeming counter-evidential, they know they have to do something ’pragmatic’.
They have been doing some of this work at Foundry PCN in East Sussex for a while. They were highlighted in the Fuller Stocktake for their approach to demand and capacity.
It involves segmenting patients into categories based on their need and funnelling them to different types of appointments to make full use of their ARRS staff.
Their clinical director Dr Philip Wallek says this approach could help people to focus on access, especially when best practice is shared.
They are working with a number of PCNs on how to make the best use of the resources they already have, whether they are coastal, rural, inner city or have elderly or young populations.
Dr Wallek says: ‘The key for us is not to do more but to work smarter. We’re all scrabbling around for what few staff there are – there is no big pot of people to provide a whole load of new appointments. The only way to do it is using what we have got in a better way by reducing failure.’
Whole system approach
But practices, and even PCNs, cannot do this alone. It has to be integrated, he says. And it takes time.
‘You can only do this by collaborating to understand the system as a whole. It’s a continuum – to find better ways of organising ourselves,’ says Dr Wallek.
For example, he says you cannot hone in on specific groups, such as complex or vulnerable patients. Instead, you must look at the system as a whole.
The hardest part at first is to let yourselves be vulnerable and admit where things are not going well, he adds.
Dr Wallek says: ‘Our ICS is being quite supportive, and they’re not expecting everything in one go, and that’s given people a bit of breathing space to get the first bit done. It should be more of a prompt to set up something, which is a commitment to ongoing development rather than a fixed endpoint.’
But what has left him scratching his head is why PCNs are being asked to look at this ahead of the publication of the NHS primary care recovery plan.
‘It’s a bit of a wrong way round to expect people to come up with a significant plan when one of the main parts of it hasn’t been released yet,’ he says.
For Dr Laura Mount, clinical director at Central and West Warrington PCN, this is all just part and parcel of how PCNs are always expected to work. They are given half the information, and the goalposts are constantly moving. ‘We’re all waiting for the recovery plan, and no one knows what’s in it. There’s a lot of ask [in the contract] for very little funds or recycled funding, so everyone is almost dreading what the recovery plan is going to say.’
During the winter, some ICBs were asking for QOF and IIF to be suspended because practices were struggling. At that time, they were told no because quality was important. But now it is Spring, and everything has shifted.
‘It’s disappointing because they must have known at that point that everything was going to be cancelled for this year. You can’t plan for a full year because the goalposts move so quickly. Even within a year, it’s completely impossible to make plans as a PCN – we have to keep them dynamic all the time. But that costs more,’ says Dr Mount.
She knows some practices will just let the 30% go because it’s not worth it. But she says they feel they have to try. So their plan is to carefully build on areas of work they were already doing around digital transformation and make better use of more senior ARRS staff.
‘We will find a way to achieve it because otherwise it’s the patients who ultimately suffer. So we will jump through the hoops, not because we think they are the right hoops but because we want to maintain services for our patients.’