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Pulse PCN roundtable: Place-based partnerships, part 1



PCN clinical directors joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss working at place level

Victoria What is the current status of work at the integrated care partnership (ICP), or place-based partnership board level for your PCN? 

Reshma In the partnership board they’re looking into the health inequalities of the area. There are various projects being undertaken in population health management (PHM) and also on developing PCN networks. There’s also work on secondary care trusts and their issues. Other proposals that are being developed include setting up diagnostic hubs. 

In our area – the Medway and Swale Health and Care Partnership Board – we’ve got nine clinical directors (CDs). I was elected to be the representative, so I sit on that board. There are other boards that require PCN clinical directorship, which is the clinical, professional and advisory board, which I also sit on. That’s probably more of use to us as PCN directors because we’re in touch with the plans on ground level – patient management and healthcare needs. 

Robin I’m not directly involved within the ICP board but as a group of PCNs we’ve got a CD representative in different work streams. These work streams include urgent care and community mental health. More recently we’ve been looking at some of the transformation [work], place-based care, health in communities, and then health inequalities and PHM. That’s a large piece of work we’re undertaking at the moment. 

Riz We’ve got very good working relationships with all the CDs, and with the community trusts as well, and we’re working closely with the acute trust. We have huge problems in Enfield with deprivation. Enfield’s a borough that is divided in two. East Enfield has huge deprivation problems and west Enfield has a very elderly population. On the east side, the acute trusts are really struggling with workload, A&E attendance and things like that, so we’re working closely to see how we can support the acute trust in managing that, how much can be taken up by general practice, how we can provide input into urgent care centres to support that system. Health inequalities are a major part of the discussions at the moment.

Victoria Robin, do you feel like you’ve got a link to the ICP? 

Robin We have regular clinical leads meetings. We have regular meetings with our primary care director in the CCG, and regular news bulletins and things like that, so we get information passed down. We are engaged and involved in particular projects as they are developed. I’ve had another role where I’ve been involved in some of the transformation work in the trust. But we’re very much a PCN in the PHM [area of work], and that’s probably one of the advantages of working with an ICP and ICS, is that they can deliver projects at scale. We’re one of 11 PCNs involved in a PHM pilot. And they’re doing that at different levels as well – at PCN level, ICP level, and ICS level. Then there’ll be other projects. We’ve got a GP who is interested in digital and is involved a lot in that. People bring their skills to the different work streams that are required. 

Victoria With place-based care operating on a larger scale, do you see PHM work happening on a larger scale too? 

Reshma I think so. In our area we’re conducting two pilots at two PCNs. They will be distributing their findings and these will be escalated. They want to see how that goes before they do that on a large scale. 

Robin It depends what can be done at scale and what can be done at a local level. I think that’s always the tension and the challenge with the top-down and bottom-up approach, and ownership, and development of services that meet your local population. As a PCN doing the PHM pilot at a local level, we’re looking at our system data, and working with our partners in the voluntary sector and the community trust, to understand and deliver something that meets that local need. But then, we can use those skills, attributes and tools on different scales, and different scales have a different agenda, and a different drive. It’s multi-level.

Victoria Do you think the GPs in your PCN are in favour of carrying out PHM as it seems like a large public health task, which is not the traditional role of a GP?

Reshma It’s a workload issue, because obviously there’s great pressure on PCNs to do lots of different types of work. We’re being pulled in all sorts of directions, and this is a massive piece of work, which is why it’s only being conducted as a pilot, because a lot of the issues in these practices could be representative across the area. This is why it’s not been done at scale presently. 

Robin As GPs and as a PCN we are very much at the heart of our population and delivering population healthcare. General practice is not just about diagnosing and prescribing. It is addressing those wider social determinants of health and working in partnership to get the community engaged and look for a wider solution to the health of your population and to the NHS. You can’t do that in an isolated manner. 

Reshma Being in a PCN has actually given us the opportunity for working a lot more with community providers. We’re having monthly meetings, getting into the crux of the issues that have affected our region for a very long time, and they’re also helping us convey that in the ICP board meetings and in the hierarchy. 

Robin For our PHM pilot, we’ve had three sessions now. In our very localised area, we’ve decided to concentrate on blood pressure in the younger population, the 30-50-year- olds, in a phased approach to try to help prevent health consequences later down the line and [look at] how we get engagement with that population. [We’re also looking at] how we address those wider health and social determinants – obesity, physical activity, smoking, which are the other key factors with hypertension. Within our PHM group, as a PCN, we’ve got representation from our patient participation group, our voluntary, public health and the community trust. It’s real partnership. Although we’ve got a very specific health aspect we’re focusing on,  we can look at all those wider determinants of patient behaviour and engagement. It’s really exciting to be part of that. The other thing we’re doing is community mental health transformation. That’s been a really good relationship across the PCNs.

Victoria Do you think the ICP amplifies the PCN voice at a system level? 

Reshma I’m only one representative of general practice on this board, and although I try to convey the message as best I can, I have to appreciate that a lot of these members have a lot of machinery behind them. They’ve got data, they’ve got internal knowledge, and so I can feel like very small fry in this big setup. This can be a huge problem and it is the worry going forward with the development of the ICSs. Is that view going to be watered down further, or will we have any direct connection to the ICS? The way they’re setting it up, [at the moment mandates] we’re only going to have one representative on that. 

My real worry is that healthcare requires a lot of clinical input and that seems to be diluted. For example, we’ve got a clinical professional advisory board, and with the restructuring they tried to get rid of it. So, there wouldn’t be a clinical input whatsoever. It’s only by standing up for it and having people say, ‘Well, no, you do need clinical oversight on all of this,’ that it was maintained.