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There is a commitment from the top to integrated neighbourhood teams but as there is no set plan and a wide definition of what they are, how do PCNs start to create a perfect blend of care for their neighbourhoods? Emma Wilkinson and Jess Hacker report for the autumn issue
Since the publication of the Fuller Stocktake in May 2022, the new NHS structure on everyone’s lips has been integrated neighbourhood teams (INTs). In her report, Professor Claire Fuller, chief executive at Surrey Heartlands integrated care system (ICS) outlined her view that this was the direction of travel for PCNs.
Across the country, all 42 ICSs have ‘accepted the mandate’ set out in her report to develop INTs, ‘which ultimately will provide more proactive, personalised and co-ordinated care to the most vulnerable in our communities’, she says.
Underpinning this new model of care are multi-organisational teams, based on defined populations, who are tasked with two objectives: to improve access to integrated urgent care and take a proactive approach for those with chronic conditions who have more complex needs, Professor Fuller explains.
These integrated teams will be ‘wrapped around practices’ and will be pivotal in stepping up action on health inequalities, she adds.
‘Understandably, different systems are at different stages of development with this, and that’s due to a multitude of factors such as relationships on the ground, different ways of working, how much integration has already taken place and so on,’ she says.
It will take time, Professor Fuller notes, but ‘progress is being made with patients up and down the country starting to reap the benefits’.
Building on links with the wider community
Cambridgeshire, Surrey, Suffolk and Leicestershire are among the places that already have staff from areas such as social care, mental health and the voluntary sector working together under this banner.
Efforts are under way in Leicester, Leicestershire and Rutland (LLR) integrated care board (ICB) to transform its PCNs into neighbourhood teams – but the move is led by the system, rather than those in the PCN.
‘We looked at what PCNs were doing, and how we could build on that to develop them into INTs,’ says the ICB’s deputy clinical director (CD), Dr Sulaxni Nainani. ‘When we started, a lot of PCNs felt this was something new but it’s really building on the work they are already delivering.’
She adds: ‘We weren’t looking much beyond the GP when we joined practices up with PCNs, but now within our surgeries we have different roles that are already linked to the wider community: social prescribers working with care navigators who are connected to the voluntary sector.’
The logical next step, she says, is to bring in local authorities, community providers and health and wellbeing boards.
In practice, this looks like a major merge of PCNs. Leicester, the ICB’s largest city, currently has around 10 PCNs that will soon become one INT, with up to 11 more INTs currently in development alongside it.
An LLR PCN may be large enough to become its own INT or it might be merged with others. That depends on its population and their needs.
‘We have taken a very varied approach in LLR. In some areas the PCNs have been large enough to develop into an INT in their own right,’ Dr Nainani says. ‘It’s about what is working already, what the population needs and how we can collectively deliver that.’
She adds that ‘when you get too broken down into structures you lose the function’ of what the INT is meant to be: services defined by a population, not a structure.
‘When PCNs were formed it was about bringing your GPs together, but we need to understand the needs of the population beyond what a general practice can deliver. Your patients might have housing needs and we’ll need to bring in the right people to support that,’ she says.
Considering a population as a whole prevents clinicians looking at problems as either primary or secondary care issues, she says. ‘We have now got secondary care clinicians doing clinics in primary care for chronic diseases because it is closer to the community. That is what you want with INTs.’
The lack of a national blueprint has raised a number of questions about exactly how and where PCNs fit in. LLR ICB is not looking at changes to additional roles reimbursement scheme (ARRS)
employment via PCNs, for example and has set out its short-term plan for its INTs regardless.
Its first year has been dedicated to setting up boundaries. Year two will turn the focus to complex, frail and long-term condition management through wellbeing hubs and same-day access to non-acute urgent care.
Frailty hubs are the focus of INTs in Professor Fuller’s Surrey Heartlands ICS. East Surrey’s Care Collaborative PCN CD Dr Pramit Patel explains that the origins of INTs in his patch came from looking at data. In a population of 200,000 in East Surrey, 62,400 people were identified as high users of healthcare services and, of those, 1% or 624 had 1,900 A&E attendances, 500 ED attendances, 500 outpatient appointments and admissions, and 54,000 primary care contacts in the past year.
‘Further analysis found that 75% of that cohort were frail so we thought about how to start reducing all that activity and get the care each person really needs,’ said Dr Patel, who is also the primary care representative on the ICB.
Adding to work done with The King’s Fund, using the primary care home model, East Surrey has set up an anticipatory care hub in each PCN. These are built around a lead GP, care co-ordinators, physician associates and pharmacists from the ARRS, along with a geriatrician, hospice representatives and community matrons working with a multidisciplinary team (MDT), including social care and dental surgeons.
This was initially financed by £300,000 of seed money from transformation funding secured in 2019 from the ICS, then still a clinical commissioning group. This paid for a GP in each of East Surrey’s five PCNs for three days a week (£60,000).
Dr Patel says: ‘If you’re an elderly patient and you’re moderately to severely frail, you will be identified and a physician associate or community matron will go out and do a comprehensive geriatric assessment. They’ll go to your home and spend a good hour and a half with you, then do proactive, anticipatory care work and bring in the right agency.’
Through this way of working there has been a ‘massive’ drop in A&E attendances of 17% and a cut in admissions of 13% in this cohort of patients.
Surrey’s Banstead INT has both an acute and proactive focus. On the urgent care side, the integrated team provides on-the-day support for patients at risk of hospital admission or needing urgent assessment at home. It consolidates GP home visiting, care home support and district nursing functions into a single acute home visiting service, also linking with the local place-based urgent community response team and virtual ward.
For proactive care, the team has a known caseload of patients with chronic conditions and can access population health management tools to identify those who may not be known to them and provide anticipatory care with MDTs. The initial focus is on people living with frailty and it will expand to other care groups.
Through links with other local services, the team has been able to get involved in a number of new initiatives, for example in care homes, with young people on the local housing estate and with the community, ‘demonstrating exactly what the new model is able to achieve over time,’ adds Professor Fuller.
‘Softer boundaries’ between services
But for many other corners of the country, the work on INTs is still in its infancy. Perhaps the team is there but not yet integrated with general practice.
Dr Tom Holdsworth, chair of Sheffield PCN CDs primary care services subcommittee, says one of the challenges is that there is no ‘off-the-shelf blueprint’ for an INT.
‘You can’t just look up a framework document that says “you need to do this”.’ He says that in Sheffield there have been a lot of discussions and some events to get the ball rolling but he is still getting to grips with defining an INT.
‘In my mind some of it looks a bit like a primary care home model where we think about GPs as one part of a wider team and our job is to try to direct the patient to the right part of the team first time.’
He adds that there is also a need to consider ‘softer boundaries’ between services instead of endless referral forms and bureaucracy.
‘If a patient comes in with a leg ulcer, I don’t do a referral form to the nurse down the corridor. I knock on the door and say “can you see this patient”. We should work in that way across a number of services that don’t just include health, such as housing, social care, mental health services, voluntary sector, district nursing, occupational therapy, physiotherapy – the whole broad patch that is working in an area.’
Dr Tom Rustom is joint CD of Healthy Horley PCN in Professor Fuller’s neck of the woods. He has been able to view the conversations on INTs from the perspective of a GP, PCN, ICS and place – as he is also CD in East Surrey.
He explains that there has been a lot of enthusiasm from the system leaders about neighbourhoods and really good engagement from the PCNs, the trust, community services and others and a willingness to make it work.
But they are aware there is still a tendency to work in the traditional siloed manner, which is difficult to overcome. ‘In the current climate, there’s probably a propensity for people to become very protectionist and cling to what they’ve got, rather than looking at this very different way of working.’
He adds: ‘If I was looking at it as a normal GP, I’d say, I don’t know what neighbourhood teams are yet. I don’t think we’re at the point where we can properly describe that to our coalface workforce.’
Dr Holdsworth agrees: ‘There is a job to communicate because everyone’s got a different vision of what an INT is.’
Starting small and building up seems the way to go. Greater Manchester ICB has written a blueprint for primary care with a chapter on neighbourhood teams.
The year one priority is to wrap care around the high users of health services, which could be small numbers of patients, says Dr Tracey Vell, medical executive lead for primary care at NHS Greater Manchester. ‘What [those groups] lack is a personal relationship with somebody that helps them access the system. I think that’s the start, and we’ll move on from there.’
Greater Manchester perhaps had a head start because it was structured around neighbourhoods before the PCN DES came in and had fully integrated social care with community nursing. But in general Dr Vell tries to avoid the term integration because it ‘smacks of organisational change’, which is both distracting and pushes people back into silos.
Instead, Dr Vell and her team are focusing on what they want to deliver and who is accountable – which might be place, provider or ICB or another body. ‘You look at the outcome and blend the team you need to reach the outcome. So the integration that’s required for, say, homelessness is totally different from the integration required for CVD or obesity,’ she explains.
To achieve this, practices will have to be connected digitally, sharing workload, and moving it around practices that make a neighbourhood, she says. They will also be pushed to move beyond their practice, for example, to deliver outside an NHS space once a month.
‘That could be mobile or in a different site or a public place or library or whatever, so we are pushing to work with a wider MDT all the time,’ says Dr Vell.
Down the line, they may do work on pulling some specialists into the community, such as dermatology, gynaecology, frailty and elderly medicine, she adds. From year two onwards the plan is to think more radically about supporting the population.
In Sheffield PCN they will most likely also start with high-intensity users, says Dr Holdsworth. Sheffield PCN already has an MDT that includes housing, social care, social prescribing and a wide range of other professionals.
‘At the moment we discuss cases we’re stuck with but that’s a reactive approach. We could flip this and take a more proactive approach,’ he adds.
But another of his goals for the coming months is to work with local pharmacies on out-of-stock medicine issues.
‘The pharmacists have really struggled to find time to engage with the network and they’re under a lot of pressure. But if we pick the thing that’s a stone in everyone’s shoe it’s something we could all start to engage on,’ he says.
Dentistry and optometry also need to be brought into the fold, he adds.
Dr Saul Kaufman, CD for St John’s Wood and Maida Vale PCN, says in Westminster one of the focuses has been housing. The PCN had been forming connections between health, the local authority and the voluntary sector in the Central London federation long before the NHS started talking about neighbourhoods. The PCN calls it the Octopus, with three hearts and eight legs being the connector roles – all working independently for the good of the whole.
‘A lot of health problems are not really health problems but social problems,’ he says. ‘If a patient comes to a GP and says “can I have a letter to move to a different council flat because I’m depressed and I have diabetes and high blood pressure”, that’s not good for the GP because it’s a waste of time.’
The data also tell them they have huge levels of deprivation and the biggest homeless population so prevention can be done in that group, making use of connector roles, he says, and ‘investing in the fabric of communities’.
In Dorset, the data indicate that elderly people are the place to start, says Dr Simone Yule, CD of The Vale (BVP) Network, but Dorset is also grappling with the concept because the term ‘neighbourhood’ has different meanings for each group involved.
‘We’re going to be looking at healthy ageing in our over-65s population because it’s such a large part of our workload,’ she says. ‘Just in my practice, we have 27,000 patients and nearly 8,000 are 65 and over. We’re going to need a wider offer than primary care to support the older age community, or PCNs can never cope by themselves.’
Dr Yule’s view is that there is absolutely a place for PCN leadership in INTs but it should not be solely about health. And there should be more than one leader.
‘That’s why I see this is a real fundamental change in how we operate as primary care and PCNs. It’s positive because it gives us permission to work more closely with the organisations in our community to support those populations.’
But it will take courage and there is an issue with permissions. ‘Every part of the system has set targets and performance indicators. We need permission from NHS England to work differently in that neighbourhood constraint, and I’m not sure we’ve got it yet,’ she says.
This can be exemplified by a piece of work Dorset is doing with the National Association for Primary Care on an out-of-hospital model. But the three organisations in involved – community care, the ICB and the GP Alliance – are all very medical when really the aim is to keep people well.
‘The piece of work is the right thing to be doing but cultures and governance are very different between organisations. How do we get to that point where we’re all signed up to working together for one or two shared outcomes?’ she asks. ‘Will NHS England give ICBs permission to grant autonomy lower down the food chain to neighbourhoods to get on and do things?’
Dr Holdsworth points out that while the contract is up for negotiation and the future of PCNs and funding streams is uncertain, there is a lot that neighbourhoods can get on with anyway because it’s about relationships. At the same time, the responsibility should not solely be placed on PCNs. ‘At the moment the PCN contract is the lever to support general practice to deliver its part of INTs. But if ICBs start to think they don’t need to do anything about INTs and the Fuller Stocktake because PCNs will do it, that’s a huge mistake.’
First you agree the vision, then you agree your part in delivering it, he adds. ‘To be fair there is a lot of work being done on this and people understand that. We’re currently in the process of writing a strategy for the ICB about how to support delivery of INTs, both for Sheffield and South Yorkshire.’
Decisions will need to be made on what can be done at regional level, at place level and at individual PCN level, he adds. For example, data sharing and information governance are broader issues and currently one of their biggest challenges.
PCNs have to be involved but they’re not the be-all-and-end-all, says Dr Vell. ‘There’s got to be a strong [concept of] the registered patient. We need strong GP leadership and strong primary care leadership and we’re developing those, but they need to be collaborative.’
The question is, she says, how you make a system accountable rather than individual organisations? Also, they need to better understand what financial reform is required.
‘This is a five-year thing,’ says Dr Rustom. ‘This is not going to change overnight. Just think about PCNs four years ago, compared with now.’
The leadership of neighbourhood teams is going to be crucial, he adds, and initially that may be the PCN. ‘Just as the CDs have been crucial in driving PCNs forward, neighbourhoods will need a leadership model, but with other organisations, not just health.’
When INTs first came on the scene, he thought the PCN would evolve into them. But he’s changed his view. ‘From the conversations we’re having now, it’s more like the PCN will dock into the INT. It’s a part of the INT, but still its own entity.’
Looking to the future: time to be brave
Opinions vary on how INTs and PCNs will fit together in the future. Dr Kaufman notes that making or even predicting national policy is difficult because everyone is in such different places.
‘My guess is PCNs will go and INTs will come, but for us it doesn’t matter because we have the federation and PCNs will work together and INTs will work together because that is what we have been doing for three or four years.’
In addition to the work on high-intensity users with neighbourhood MDTs, Dr Holdsworth hopes that in a year from now his PCN will be on a better footing with information sharing and information governance, and that the ICN will be building relationships on a wider and wider scale. Local services, including adult social care, are in the process of aligning boundaries, which will help, he adds. ‘I would also like to have dismantled barriers to services that require GP referral so our social prescribers and other team members can refer directly,’ he says.
INTs don’t themselves have the ability to change the fact that 80% of health is socially determined, notes Dr Vell, but she feels that this time they really do need to do things differently.
‘We have to get public opinion on side first to understand what we’re trying to build, which is where we’ve been going in Greater Manchester. But NHS England is still old school, in our opinion,’ she says.
It is the time to be brave, says Dr Yule. ‘This could be a really positive fundamental change to care and wellbeing but the risk is that we carry on in that same narrow health focus, just doing a redesign of services rather than thinking about the whole community.’
It’s clear that the ambition set out in the Fuller Stocktake for INTs is very much in the early stages in most places, a stage of definition rather than action. CDs see PCNs as a core team player but have questions about how it works practically in terms of leadership and funding.
But as PCNs wait for details about their future it’s clear that everybody is on board with the idea that good neighbourhood working is needed to find the perfect blend of professions to provide good care for patients and that there is no need to wait.