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Collaborative working and ‘breaking down silo working’ are buzz-words we have become familiar with. But what does it actually mean, and how do we actually set about doing this as PCNs? Collaboration can and should happen across a wide spectrum of organisations and clinical teams, but this article will focus on how PCNs can collaborate with hospital consultants.
In our PCN, we have set up multiple levels of collaborative consultant working.
Consultant led community clinics – consultants working without GP’s, but perhaps with other PCN staff for administration support.
Joint working GP with Extended Role (GPER)/consultant clinics – with GPERs working alongside or in joint clinics with consultant colleagues.
Consultant input into wider MDT clinics – virtual or in person support to MDT working between our PCN staff, and often community trust staff; in our PCN diabetes and frailty are benefitting from this.
Having consultants in the PCN geography, often in practice buildings, not only allows for care closer to home, but also forges much closer relationships between consultants and the primary care team. Literally being under the same roof as the wider PCN team, perhaps sharing a coffee between patients and discussing cases certainly allows for a more unified approach to patient care, hopefully a better patient care pathway, better outcome as well as better professional satisfaction for our teams. Improving internal efficiency in General Practice should also not be overlooked. As Pulse reported that poor hospital interface ‘wastes 15m GP appointments per year’. If a PCN can have greater control on the interface itself, then we could possibly reduce this significant source of wasted capacity.
Choosing the right specialty
There is no single formula to developing these services. Choosing the right specialty area is important. In our experience there are certainly specialties and services that lend themselves to community provision and collaboration. Ophthlamology, ENT, dermatology, cardiology, frailty and MSK services are examples that have proven to be effective in our area; there are many other examples or excellent collaboration up and down the country. Of course, any decision to explore collaborative working must also be driven by patient need, population health data, and considering where pressures may exist in local secondary care systems. Having robust data understanding what would benefit your population is essential in building a business case.
In our experience, the most productive collaborations occur between named individuals, rather than intangible concepts such as ‘departments’. These driving forces may be interested PCN staff, consultants, PCN managers, or commissioners. Having shared ownership, and a mutual desire to develop a service, led by specific individuals is vital. As a starting point, getting to know your local consultants, and understanding what possibilities exist, is a good first step to exploring opportunities to collaborate.
Having identified a need, and agreed with your like-minded colleagues on a clinically driven community/collaborative solution, you then have to translate this into a delivered service.
Barriers to development are not insurmountable, but they are significant. A barrier that we often don’t want to confront is the possible conflict and competition between providers. Better patient care, improving the patient journey, and possibly even providing care at lower costs are all significant reasons as to why all of us should agree enabling this is so important. We know waiting lists, and demand, are at an all-time high, and we need to find solutions to this; collaborative community clinics certainly have a role in solving the current crisis.
Estates, and IT are perennial barriers that also need to be addressed if considering expanding community provision.
Support from our commissioning colleagues in our ICS, appropriate funding and contractual mechanisms where needed, and support from our excellent managers in the PCN’s and Trusts is vital, as is a flexibility from Primary Care, to enable this development.
Health and Care Partnerships, and Integrated Neighbourhood Teams, are examples of structures that may facilitate this working. I would caution, however, that in order to achieve maximum benefit, the scale of the collaboration I have described has to be appropriately local to allow the relationship connections, rather than it being an abstract concept at large scale that is no different to existing pathways.
Beyond actual service provision, another way PCNs can connect and collaborate with consultants is through better communication through education and relationship building events. Re-building those personal relationships between PCN staff and consultants, particularly given the Covid era hiatus should be high on our agendas.
An innovative idea to help break down the ‘silo working’ is to look at ‘exchange working’; perhaps a wider extension of the GPER/consultant joint working, or MDT work, this could include shadowing in a bilateral agreement, where GP’s, or other PCN clinicians shadow consultants, and vice versa, to better understand the issues each face, with a view to improving efficiency and patient care.
In the current climate of constraint, primarily in workforce, with pressures on appointment provision and waiting lists, it is perhaps difficult to achieve – such a scheme in our area has been in the making for some time, but is yet to come to fruition.
However, perhaps we need to be bold in order to break the negative cycles. We should accept investment, be that in time or personnel, or by new ways of collaborative working that may pay significant dividends in efficiency, improved patient care, and better workforce retention in the future.
Dr Jeremy Carter is clinical director of Herne Bay PCN, Kent; executive partner at Park Surgery, Herne Bay; director of Herne Bay Health Care and on the Pulse PCN editorial advisory board