Opinion: What has the new system done for PCNs?

Clinical director of Fareham and Portchester PCN, Dr Kieran Gilmartin, reflects on the interactions between primary care and the Hampshire and Isle of Wight integrated care system

It has now been nearly a year since the inception of integrated care systems (ICS) and integrated care boards (ICBs). The question I ask myself is: has anything changed for PCNs and primary care? And if so, has it changed in a good way?

My instinct and experience makes me suspect that things are heading the same way they always seem to go when decision-making moves further away from the front line. It tends to lead to a feeling that primary care has less influence, not more.

This seems to be the case again. When it comes to making a difference, primary care is further away from being able to affect the change needed across an ICS. We have no voting power on decisions being made at the ICB. When the Fuller Report mentioned a bottom-up approach, I hoped the ICB might adopt this stance. But it does not seem to be forthcoming. 

In fact, the thinking seems not to have changed at all. This was my impression when I attended ICS meetings as part of the urgent care strategy. I was there with an entire room of senior leaders from all aspects of the system. And nothing much seemed to have changed. It appeared that, as always, the same approach was being taken – and once again, primary care was being left behind.

Local support

The local support we had from our CCGs colleagues, who are now in the ICB, is still there. They were – and remain – very supportive. But how much say they have in the newly formed ICS is uncertain. Even though they try to voice our concerns, they seem further away from the actual decisions. This is at a time when the ICS is reducing the staff numbers, which makes no sense when systems are struggling every day.

As clinical director, the most useful support comes from my counterparts at other PCNs in our area. We meet every week as we have done since 2019. Of course, each PCN has slightly different needs, but we are united in a common goal – to keep going. After all, if one struggles or falls, it will impact us all.

Despite my apparent cynicism, I have always wanted to do the best that I can. However, this is made more difficult by the last-minute requests and guidance issued from NHS England and the ICS. We need to get rid of the top-down approach and start listening to those on the ground. They will highlight the issues and tell us what is required. That approach will get us much further than trying to hide problems or making primary care the scapegoat, which is often the default position.

Uncertain future

The future looks difficult, but I want to make things better for my staff and patients. Most of my colleagues would say the same. The trouble is that if things continue along the same lines as always, we will lose staff, and there will be even fewer people to do the work our patients need.

Is there a simple answer? Of course not. But it is clear that we need to change the approach. It is time to move away from those at the top thinking they have the answer. Instead, they need to recognise that doing the same thing – again – with a different name will not work. It will still fail to improve patient health and staff retention.

We have to be honest with patients about the problems faced by our system and primary care. There needs to be support from the ICSs. And NHS England has to agree – and be vocal in its agreement – and work with us for long-term solutions with realistic expectations.

To put long-term plans in place, we need long-term funding. That allows us to put plans in place knowing what the future holds rather than the major uncertainties we have now because GMS and PCN DES contracts are running out next year.

In short, my ask for the future is that those on the frontline get an actual say in the big decisions. And if we say they will not work?  Listen, and don’t just push them through.