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PCNs are focusing on delivering care differently for their populations. We look at the evolution of PCN hubs and examples from across the country. Jess Hacker reports
A movement is gathering pace as PCNs come to the final straight of their five-year contract.
PCN hubs are in use across the country, with practices analysing their populations for problem areas and pooling staff and resources to treat them. The concept is simple: a service led by a PCN, using its collective resources, to target an underserved group or local health crisis.
The origins of this are the innovations forged in the Covid-19 pandemic, which – for all the devastation it wrought – is now regarded as a key accelerator for NHS integration.
Within weeks of the first national lockdown, GP practices had set up ‘hot hubs’ across at least 12 former clinical commissioning group (CCG) footprints – including North West London (NWL) and Gloucestershire – to diagnose and advise coronavirus patients in the community. By early April 2020, NHS England was advising practices without a hot hub in their PCN to identify a surgery to host one.
These Covid hubs laid the foundations of what would become PCNs’ best chance to innovate and create an entirely local service for the specific needs of a PCN’s community.
Now PCNs are showing they are putting their additional roles reimbursement scheme (ARRS) staff to good use and building on the tight-knit relationships made in the pandemic. As a result, integrated care systems (ICSs) are now looking to hubs as the jumping off point for the PCN’s successor: integrated neighbourhood teams (INTs), proposed in Dr Claire Fuller’s 2022 stocktake review.
Dr Fuller also looked ahead to solving the GP estates crisis with hubs in ‘each neighbourhood and place to co-locate integrated neighbourhood teams’.
Hub is something of a misnomer. A hub is not a specific place or a purpose-built surgery, although a PCN might have one of these too. A hub is more akin to a care pathway or a specialist clinic, designed to deliver a particular kind of care.
In some cases, a hub can tackle an inequality that would be near impossible to tackle at a higher level, and its small size grants it the agility to zero in on precise barriers to access.
Where so much work in general practice and the wider NHS is governed from the top down, PCN hubs are successful because of their ground-up approach.
In the heart of the capital, PCNs in Westminster have been running a series of children’s health hubs to increase access to specialist advice and ensure good quality onward referrals.
Analysis led by the Royal College of Paediatrics and Child Health found that 350,969 children were waiting to be seen by a consultant as of April 2022, an increase of 100,000 on the year before.
With social deprivation comes poorer access: Westminster is often perceived as affluent, but there are high levels of deprivation. According to Local Government Association analysis, Westminster has 2,399 children in working families of relatively low income. Research published by the Health Foundation in 2020 has highlighted that in more deprived areas there are fewer GPs per head, and a GP working in a practice in a deprived area is responsible for the care of almost 10% more patients than a GP in a more affluent area.
‘Children in Westminster face a lot of health challenges. They deal with poverty, obesity and asthma, and we know there are real issues with gangs and county lines,’ says Dr Niamh McLaughlin, a GP working in South Westminster PCN and the maternity, children and young person (MCYP) GP lead for North West London ICS.
‘That’s a real range of physical and social needs but we often tend to look at them individually.’
So 17 out of North West London ICS’s 45 PCNs run a child health hub, a clinic staffed by a GP and a paediatrician under one roof, accompanied by a virtual meeting run by a multidisciplinary team (MDT).
If a GP has a concern about a child they have seen in practice – for example, with chronic abdominal pain or headaches – who is not acutely unwell, they will refer them to their PCN’s child health hub. This is a two-hour clinic held once a month offering six 20-minute appointments. If a problem cannot be resolved at the clinic, the team can refer the patient.
The online MDT clinic is staffed by health visitors, school nurses, a family hub team, dietitians and child and adolescent mental health services (CAHMS) professionals. These CAHMS staff help manage patients who present with mental health concerns or eating disorders.
The hubs offer families help closer to home. As they offer a breadth of clinicians, GPs remain a part of the shared decision-making.
Working relationships between primary and secondary care are also improved.
It is important not to undervalue that working relationship. GPs, paediatricians and other members of the team are not paid for their time working in the clinics. The model relies on those staff members’ goodwill. It also relies on the providers recognising the benefit of redeploying their staff.
‘Much of it is dependent on the willingness of the PCN, which can see the benefits to their patients and the workforce. And also the acute trusts, which can see the benefit of redeploying their staff to work in a different way,’ says Dr McLaughlin, whose PCN hub is staffed with a paediatrician from the nearby Evelina London Children’s Hospital.
‘Locally, PCNs naturally have an alignment with acute trusts. One of their motivations is that the hub reduces referrals to secondary care – so inappropriate referrals are reduced, and more people are seen who should be seen, which has a positive impact on waiting times. There are benefits to the system they have to consider.’
Since May 2022, routine general paediatric hospital outpatient attendances have reduced by approximately 30%, while GP attendances have reduced by around 32% as a result of children being discussed and managed through these hubs, according to data from Evelina London Children’s Hospital.
Dr McLaughlin says patients with complex mental, physical and social health cases tend to benefit from the system and staff have an increased sense of job satisfaction.
‘If I have a case that requires CAHMS input, for example, I have the time to speak with the clinician to make sure they have all the relevant information for the patient. It’s a much more effective and efficient way of working. I want to refer someone to the right place, and I am confident I can do that, rather than sending out three referrals and hoping one is correct. And from a system perspective, having the children seen effectively and efficiently saves money in the entire system.’
The ICS has recognised this benefit to the system too. The hubs have been pivotal in researching and developing the footprint’s INTs: a model suggested by Dr Fuller as a successor or progression of the PCN model.
A spokesperson for NWL ICS said: ‘The child health hubs are making a difference to children and their families. By focusing on babies, children and young people, we are supporting the wellbeing of the whole family and future healthy adults.
‘Child health hubs illustrate the value of working with the primary care team, making best use of the resources in the local system. The ICS has been sharing the learning from the child health hubs with other child health teams across the country and in the establishment of INTs.’
Liverpool women’s health hubs
In Liverpool, six of the city’s nine PCNs have been running women’s health hubs, offering a wide range of sexual health services – including fitting long-acting reversible contraception (LARC).
These hubs – each led by their PCN – were commissioned by Liverpool City Council in response to a staggeringly low rate of uptake for the contraceptive method, with the first hub launching in February 2020 in North Liverpool PCN.
‘The background when we launched was pretty alarming,’ says Dr Stephanie Cook, a GP in SWAGGA PCN, which runs one of the city’s women’s health hubs across two sites.
‘Our LARC uptake in primary care in Liverpool was around 13 per 1,000 women, compared with a national average of around 30 per 1,000. And in some areas – such as where the first hub started – we had a very high number of unplanned pregnancies, with high termination and high repeat termination rates.’
Historically, LARC uptake in primary care fell drastically across the country. At its peak, the rate of LARC prescribed by GPs stood at 32.3 per 1,000 population in 2014, according to Office for Health Improvement and Disparities (OHID) data. But this rate declined to 29.2 in 2017, and fell as low as 21.1 in 2020, and never quite recovered.
Training practice staff to fit an LARC is often deemed a significant time-sink, and providers often struggle to find trainers. Where a practice does have a trained fitter, patients are often not aware of the service. LARC fittings are not big money-makers for general practice, as with any procedure that occupies a valuable room in the surgery. And these issues hit harder in places of high social deprivation.
But Liverpool’s women’s health hubs offer an easily accessible service for women on a cost-effective model.
Between the six PCNs, the city has women’s health hubs operating out of 11 locations, the majority of which are based in a PCN member practice.
The majority of LARC fitters are GPs and nurses. The service is funded primarily by local enhanced service (LES) payments, held by the local authority, at £100 per procedure run by a GP – but the best business case is in the use of the ARRS staff.
If a PCN can recruit advanced nurse practitioners (ANPs), physician associates and clinical pharmacists – who are equally qualified to fit an IUD – into an ARRS role, the cost of staffing the hub is neutralised and the only additional cost is equipment.
Similarly, if the telephone triage can be delegated to an ARRS role such as care co-ordinators – as most hubs do –and nursing associates, this minimises cost.
Central Liverpool PCN offers its clinic at weekends, taking advantage of the enhanced access funding to cover the running costs and offer a convenient service. The PCN has three sites for its hub, including
a clinic operating from its own dedicated site. With this site, the PCN is able to run five days a week, offering six slots each day.
The hub model in Liverpool has nearly doubled the number of LARC procedures in Liverpool over the past three years.
In 2019-20 – before the first hub launched – there were just 2,798 procedures to fit or remove an implant and IUS or IUD in Liverpool across the year. That number jumped to 5,102 across the whole year in 2022-23, just over three years since the hubs launched.
In North Liverpool PCN, as few as 15.5 women per 1,000 had an LARC fitted in 2018-19. As of 2022-23, that number now stands at 25.9 women.
And in SWAGGA PCN, the figure jumped from 20.7 women to 29.4 women over the same period.
Liverpool City Council’s sexual reproductive health and HIV commissioning lead James Woolgar told Pulse PCN: ‘In terms of the return on investment, one of the modelling pieces showed we could save around £80,000 in the number of patients [going to secondary care for] pessaries and some IUDs.’
‘We’ve had a steady rise across all the PCNs ever since with an overall 150% increase in procedures in Liverpool on pre-pandemic levels. There are lots of services across the country struggling to hit even their pre-pandemic levels, let alone improve them,’ says Dr Cook, who is also on the board for the Primary Care Women’s Health Forum (PCWHF) which helped design the model.
But Dr Cook says the hub model ‘doesn’t have to be a physical space or a purpose-built, brand-new building’. Instead, these hubs are about ‘pulling together and sharing your staff, your resources and linking those existing services to improve access for women’.
Dr Cook suggests the network of hubs itself has strengthened the working relationship between the neighbouring PCNs, having encouraged stronger connections between staff.
‘It’s been a real trailblazing service and has brought connectivity across the PCNs, which has been vital. At the end of the day, PCNs have to work together and share services and resources. The hub is a great example of that journey.’
This burgeoning relationship between providers appears to be a key indicator of success in other hubs and also ties into the push from the centre to have primary care working at scale. And it is also clinician led and patient centred.
The estates crisis, while not directly about workforce or patient care, is no less pressing.
In a 2022 report, the NHS Confederation urged the Government to provide ICSs with quicker access to capital funding to invest in the NHS estate, and a Pulse PCN survey with just under 200 GP and clinical director respondents found 72.8% do not have the space to house their additional roles staff.
In Rochdale, Greater Manchester, Middleton PCN’s hub aimed to tackle both estates and access.
Located on the first floor of Middleton Shopping Centre next to a WHSmith, the primary care hub offers patients access to NHS services from the heart of the community. The practices benefit from the site’s six consultation rooms – enough space to house the PCN’s ARRS staff.
Launched in May 2023, the hub initially offered social prescribing link worker (SPLW) and phlebotomy clinics, and had three mental health staff working on site.
By the time of publication, the hub will also have an HIV service, and plans to offer broader sexual health services.
Plans are also being developed to turn one of the consultation rooms into a diagnostics centre, to offer spirometry, FeNO testing and ultrasound scans.
Middleton PCN clinical director Dr Mohammed Jiva says: ‘We started from the same position as everybody else with a lack of estates and GP surgeries.’
The PCN was first given the space free of charge during the Covid pandemic to deliver vaccinations.
‘After that, the unit went back to being an empty shell of breeze blocks,’ says Dr Jiva.
The network assessed the opportunity. The location would allow for greater footfall which would improve access. Patients could attend a clinic and collect their prescription in one trip. And if the hub could offer a wide variety of services, there would be less demand and shorter waits for an appointment in the practice.
The PCN took the concept to its neighbouring healthcare organisations and recruited three partners in the GP federation – Rochdale Health Alliance, Rochdale Borough Public Health and HMR Primary Care Academy.
Each partner contributes to the running costs with its own funds. The PCN covers costs from the investment and impact fund (IIF).
‘We topslice our annual IIF achievements to keep the whole hub running, and the rest of the IIF is invested in staff and workforce across the PCN,’ Dr Jiva adds.
The hub is too new to have concrete data on outcomes, but the PCN will measure its success through patient feedback. Already, Dr Jiva is keenly aware of the immediate benefit to GPs.
‘With the additional estate, it will allow us to manage more patients and shorten waiting times.’
Hub working is on the rise in a changing NHS. Major reforms last year completely reshaped the way the NHS commissions services, but PCNs are keeping an ear close to the ground, working for themselves and innovating on their own.
In a review of women’s health hubs, led by the Birmingham, RAND and Cambridge Evaluation (BRACE) Centre, researchers found that the definition of a hub varied significantly, and the assorted functions were likely to confuse women, health professionals and policymakers. But it is that diversity that can give hubs the edge in providing care tailored to their populations.
‘Top-down standardisation may hinder this,’ they concluded. ‘It is likely that a balance needs to be struck between standardisation and locally defined models.’
Where much of the NHS is dictated from the top down, PCN hubs demonstrate the success of working from the bottom up.
And that is being noticed – NWL ICB is reviewing its PCNs’ child health hubs in preparation for the next phase of primary care delivery.
Ruth Rankine, director of primary care at the NHS Confederation, describes PCNs as a mechanism for clinicians to come together to understand the needs of their population because ‘those services are not currently delivered and they have identified a gap’ to fill.
‘Although the journey is not always smooth sailing, some PCNs are already beginning to see the benefits of this integrated approach,’ she says.
‘The approach showcases the intelligence, tenacity and goodwill of primary care leaders and their teams coming together and navigating through the structural challenges to deliver for their patients.’