In the second part of the Pulse PCN discussion about working at place level, Pulse PCN editor Victoria Vaughan asks clinical directors about representation at ICS level
Victoria Does your Integrated care partnership (ICP) have a representative at ICS level yet?
Reshma No, and it’s not very obvious how that selection’s going to be made. I don’t think it will necessarily be a clinical director (CD) from a PCN. It could be any GP.
Robin We have a number of ICPs that feed into our integrated care system (ICS). Each of those place-based boards has a GP CD, ours isn’t a PCN CD, and they then represent the ICP in the ICS. Our ICP has a PCN primary care clinical lead, but I am not aware that this role is replicated in the other ICPs and it isn’t represented at the ICS.
Riz Ours is a slightly bigger system because we have the North Central London (NCL) ICS, or currently the NCL CCG, so our five borough CCGs combined to become a CCG, and that’s where the ICS will sit, and each of the boroughs will have their own footprint within that. The system will be quite large and it’s unclear how much of a clinical voice from general practice will be on that board and how can it represent such a large group, as each of the boroughs have very different needs. How do we keep that place-based partnership in the boroughs as well as at the NCL level, to meet the individual needs of each borough? The whole idea with the PCNs was to meet local needs and small was beautiful. Now suddenly everything has changed, and getting away from that. That whole bottom-up approach… we might start losing some of that if it’s coming from above. We need to build up trust that we’re all doing it for the same reasons, and I feel that there’s a risk that we might lose some of that trust and that ethos of equal partnership. It feels as if it’s in the balance, and that the GP voice might be lost.
Victoria How worried are you that the foundations you’ve been laying as PCNs are being undermined as the system develops?
Riz There is a concern. We’re trying on a borough level to make sure we still work collaboratively and have a distributive leadership model where different PCNs can say, ‘I can do this’, and we learn from each other. If one PCN has a greater need, we try to focus some of the funding towards that site.
As I said, in the east of Enfield, we have a real issue with inequality, so we say, if that’s where the need is, that’s where the funding should go. Having that sort of relationship is easy when there is trust behind it, but as it gets bigger and bigger, [there is a]worry that those decisions will be taken out of our hands and I’m not sure we’ll get the same results at the end.
Victoria What’s the danger of the ICS not listening to the PCN voice?
Reshma It’s a huge concern, because the ICS for Kent and Medway will cover 42 PCNs. CCGs have amalgamated into that one Kent and Medway CCG, and already we’ve noticed they’re a little bit more distant from us. We’ve lost a bit of that knowledge. Even though we’re all Kent, we all have slightly different issues. There are more deprived areas, such as in Swale and Thanet, so [it’s difficult for the ICS to make sure each region is heard and not treated unfairly]. I’ve always said in our ICP board, ‘Please, what are the discussions with the other [three Kent] ICP boards?’ We need to be more collaborative so that we will have some kind of positive outcome.
Robin It’s such a difficult challenge. I was involved in another project before looking at the equity of services across the whole of the ICS, instead of piecemeal at ICP level. Historically, we’ve had four or five CCGs commissioning and funding individual services slightly differently, which has led to inequity of services. We have the advantage that the ICS can give oversight and say, ‘these are the standards we expect across the entire ICS. This is the best evidence approach’. But how [should that be] delivered at a local scale and where [should it] be done? The ICS is about being able to channel that resource [alongside] wider oversight and outcomes, rather than saying, ‘This is specifically what you must do in this area, and we’re expecting you to deliver this outcome at X, Y and Z’. It’s tools they are giving us to respond in a local way and have local ownership and autonomy in the ICP or at PCN level. As an individual PCN we are very small. We’re lucky that we are, but we’re trying to bring [even smaller units like] individual GP partnerships together to work as one PCN and have a voice within an ICP and have that voice represented at ICS level. That’s very difficult when there might be an acute or community trust that has a much larger voice. [There is] a huge tension about acute trusts; there always has been, [as long as] I’ve been involved in these sorts of roles. The priority ends up being to support the acute and emergency department or elective admissions.
Victoria Do the ICPs and place-based partnerships help with this as they involve the acute trust?
Reshma It’s always about the acute trusts. It’s always about crisis point. Now it will be about Covid again, as the cases go up. ‘Please stop admissions. Stop people coming into ED.’ [There will be a] pushback into general practice and an increase in workload, and a workload transfer as well. We did a huge survey that demonstrated how much workload was being transferred from secondary care to general practice, so we’ve got these issues to deal with. The problem is that the funding should follow the patient and general practice does 90% of the consultations, whereas only 10% of the activity [is done] in acute trusts, but that’s not conveyed in these discussions.
Riz The problem is the acute trusts seem to have a louder voice. That catches the media a lot more in terms of the long waiting times in the ED. As a result, the funding will follow. We can have those conversations with the acute trusts, but nothing comes of them because their agenda is very different from general practice’s agenda. And sometimes, it’s hard to have the conversation about how things could be done in a different way in their ED, to get them to grasp that general practice delivers in a very effective and efficient way, and perhaps they can learn
Victoria What’s the potential of the PCN working with the ICP or partnership board and what’s required to meet that?
Reshma We have a really good working relationship with them. It’s very difficult to say what could be achieved. It will probably be more of the same. We have our own workload and our own targets to address, and the ICP also is trying to work on that. It all comes down to funding, [time and workforce]. A lot more funding is needed for the deprived areas. We need time to engage with meetings and be able to input our thoughts. We also need the workforce. It’s always these things that we need.
Robin I think [we need an] acknowledgement that outcomes take time to deliver, that there are disparities and different priorities even within one ICP. Acknowledging this will enable us to deliver at an ICP level and an ICS level, along with funding and the sharing of workforce, of ideas of what has worked well and what hasn’t. How do we collaborate as ICPs instead of remaining as fragmented CCGs? And why are we not putting more funding into public health and supporting that?
Riz The main issue for the PCNs is having the headspace. At the moment, we feel like headless chickens going from one thing to another, not being able to give our full time and energy to any project fully. It’s meeting after meeting, and I think all the CDs are struggling. I think there’s a lot of enthusiasm and people want to do the best for both their patients at a PCN level, borough level and ICS level, but I feel there just isn’t enough capacity, and the workload is going up. I think they’re being dragged in to get their clinical work done as well as all the administrative and managerial work. That clinical leadership is struggling just to get the time to do that, and yet, it’s so necessary at each of these levels to have adequate clinical leadership.
My biggest worry for the future is how we will develop future clinical leaders. I can see people at the moment are going to either burn out and step down or are coming close to retirement. How are we going to get the younger generation involved in leadership at PCN level, [partnership] board and ICS levels?