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Tower Hamlets in east London is a leading light in primary care innovation. Tracy Cannell and Chris Banks, joint chief executives for the Tower Hamlets GP Care Group federation, explain how PCNs are working in the borough
Tower Hamlets has several challenges – some of them like other cities, some of them unique. We have a high population density with 325,000 people living in less than eight square miles, and the youngest average age in the country.
Our community is ethnically diverse with 32% white British and 32% Bangladeshi, with a 20% churn of residents. We have a lower healthy life expectancy at birth: for men it is 60.5 years and for women, unusually, it is even lower at 57.6 years. These figures are well below the average for London (80.9 years) and England (79.8 years). There are high levels of child poverty, child obesity, severe mental health problems, homelessness and early deaths due to cancer, heart, circulatory and respiratory disease. We also have high levels of pollution and, recently, comparatively lower levels of Covid vaccination uptake.
Innovative care provision
These challenges led Tower Hamlets to innovate in care provision. More than 10 years ago we established eight networks, which set us up well for the introduction of PCNs. In 2015 the Tower Hamlets GP Care Group federation was set up with nothing but our ambition to grow a strong integrated primary care-led system to improve care and outcomes for a very deprived community.
The GP Care Group is owned by all the practices on a not-for-profit basis. We have grown from four staff and a turnover of £242,000 to more than 600 staff and a turnover of £34m. We are one of the largest community focussed primary care federations in England, and we work closely with the local council and other partners in the NHS and voluntary sector.
Every service we took over had been failing. Now they are high performing, they produce better outcomes, improved patient and staff satisfaction, and fantastic value for money.
Unfortunately there is no mention of federations and working at scale in national policy plans. Our federation has delivered major benefits including online access to all of our practices and face-to-face care 24/7. We offer one of England’s best performing 0–19-year-old services. We have set up social prescribing, acute phlebotomy and a virtual Covid ward caring for 260 patients at a time. The federation has also reduced urgent care costs by more than £1m, reduced estate and IT costs by 55% and reduced pre-Covid staff sickness from 10% to less than 3%.
Primary care still struggles to be heard as loudly as large trusts in many local systems. Having a GP federation of all PCNs and practices has helped us achieve this. It also lets us deliver at scale on behalf of all PCNs where appropriate, reducing duplication and achieving more, faster because of the focused and experienced management support that is not available at a PCN level.
This was never more evident than during the height of the pandemic. Before the end of March 2020, we:
• Set up a Covid lead group involving PCNs and the LMC.
• Agreed a plan for primary care.
• Set up a 24/7 integrated primary care service providing face-to-face support and home visiting to all our practices, keeping services going when they were closed because of staff isolation or illness.
• Established a central virtual ward with home monitoring, taking referrals from practices and hospitals.
• Set up a local test and trace service very rapidly in partnership with the local public health team from the borough of Tower Hamlets with a multilingual staff team.
Introduction of PCNs
Since the Network DES was introduced in 2019, our networks have all become PCNs. The transition was straightforward. However, there was some unravelling of plans for co-ordinated borough-based work
because the focus of government policy is on individual PCN development, rather than collaboration at a borough level. For example the extended access hubs have been provided at a borough level, which all registered patients in the borough can access. With the move of funding from CCGs to PCNs there is a risk that PCNs will not continue to collaborate in this way, as some are planning different arrangements, which may reduce patient choice.
Because the networks (now PCNs), were already well established the focus has been on establishing the roles of the CDs and how to use additional roles reimbursement scheme (ARRS) monies. The PCNs all appointed CDs, many of whom were already leading the networks. However, the CDs have limited time and limited direct management support. We meet regularly with the CDs as a group and employ the management that supports them.
Initially, lack of recognition of additional pay costs in London, limited access to NHS pensions and the pandemic all hampered PCN development plans. We have supported PCNs to recruit additional roles including pharmacists, physiotherapists and occupational therapists. We have requested more flexibility for extended roles, and as we are an NHS employer we can offer staff good support so recruitment has not been difficult.
The introduction of PCNs has provided more funded time for clinicians to develop networks. This has led to local innovations, for example long-term condition (LTC) management with multidisciplinary teams (MDTs) at a network level.
It has also meant we can take a tiered approach to supporting practices, for example, with Covid vaccination. All the practices in Tower Hamlets signed up to a borough-wide arrangement led by the federation with borough-wide clinics and a booking helpline, a central roving team to support 68 care settings and pop-up venues. The majority of housebound patients were vaccinated by practices with support from the roving team. Practices have also held vaccination clinics to increase uptake. This has meant that practices have been able to largely continue focussing on their mainstream priorities.
Over the past five years, a key lesson we’ve learned is to evaluate options for service development and delivery to scale cost effectively. Our population doesn’t like to travel, so we provide care as close as possible to them and work with the PCNs to evaluate the most cost-effective approach.
Having a well-established federation with mature partnerships means issues can be resolved very quickly. Recently, this included borough-based Covid home monitoring, 24/7 primary care and a vaccine helpline. We also work closely with the borough council which invests an enormous amount of time at senior level to improve the health and wellbeing of residents. The culture of primary care in Tower Hamlets is one of collaboration.
We want to increase our borough-based digital offering. Over the past few years we have developed and implemented online consultation across all practices. We have both web-based forms and video consultation,
as well as two-way text messaging – and this really helped maintain care during the pandemic. We implemented centralised online registration and are now exploring how we can provide a portal at scale to help individual practices meet needs on a 24/7 basis.
We intend to fully implement personalised care planning for both adults and children with patient-held care plans. This will reduce the fragmentation of care and will help patients to lead their own care. We already have a team of social prescribers linked to each network.
We are actively helping to reduce poverty of children and older residents. For example, we have a project that covers two of our networks helping families to access benefits.
We also campaign to reduce pollution and be an environmentally conscious primary care service. We have declared a climate emergency as a board and are taking active steps to reduce our carbon footprint. This includes adopting re-useable masks in the pandemic.
Covid and recovery from Covid are a key focus, and this includes supporting primary care staff. Early in the pandemic we set up a third-party counselling and support service for PCN and practice staff, which has been well received. Uptake has been high, so we are continuing the service. Staff empowerment is key to success. Throughout Covid we held webinars for primary care staff to identify and explore issues, develop solutions and shape plans and we continue to do this.
Collaboration, dedication, professionalism, support and respect are the key ingredients of the primary care system in Tower Hamlets. Our focus is on making residents’ lives better and we feel very privileged to be part of it.
Chief executives Tracy Cannell and Chris Banks
Federation Tower Hamlets GP Care Group
PCNs Tower Hamlets has seven PCNs: The One network; East End Health network; Tower network; Bow Health network; Mile End East and Bromley by Bow Health network (MEEBBB); Poplar and Limehouse Health network; Healthy Island Partnership
Number of practices in the seven PCNs 35
Number of registered patients in the seven PCNs 325,000
PCN hires 20 clinical pharmacists, 10 social prescribers, eight first contact physiotherapists, seven care co-ordinators, two health and wellbeing coaches, three occupational therapists (not all at FTE)
Recruiting Still looking for seven clinical pharmacists, three social prescribers, four care co-ordinators, two first-contact physiotherapists, one health and wellbeing coach, one physician associate, three mental health practitioners, one nurse associate, three trainee nurse associates, one dietitian and one pharmacy technician