Profile: Kernow how

While Cornwall will be this summer’s domestic holiday destination of choice, Dr Dale Staff and Dr Mike Waldron tell us how their PCN is planning care for locals in all seasons 

Bosvena Three Harbours PCN covers a varied geography and patient demographic, which includes a large portion of remote Bodmin moor, some central Cornwall urban areas such as Bodmin Town that have high deprivation, and the popular coastal harbour town of Fowey. The new PCN footprint crossed some historical boundaries, which made the initial set-up challenging.

The PCN is made up of two clinical neighbourhoods which were in different CCG locality groupings. The Three Harbours group moved from the Mid Cornwall CCG locality to North and East to accommodate this. The community healthcare teams and social care were aligned around the old boundaries, so this change has affected more than just the practices. We have begun aligning the community teams such as district nursing, but there is still a long way to go with other services.

The two Bodmin practices were already working together under the name of ‘Bosvena’, as were the practices in Fowey, Lostwithiel and Middleway as ‘Three Harbours’. Each group considered applying to be individual PCNs but they were too small. So an application was submitted for one PCN, in which we planned to maintain two clinical neighbourhoods. Dr Dale Staff (Bosvena) and Dr Michael Waldron (Three Harbours) run the PCN as joint CDs with two strategic managers. As time has gone  on, these boundaries have blurred. 

Management structure

Once we decided on our make-up, agreeing and signing the PCN agreement was straightforward. But how to organise the management of the PCN was a dilemma. We considered a standalone strategic manager, but decided we didn’t want to see the PCN as a bolt-on to GMS, we would integrate it fully with our practices. So we freed up time from the management team and expanded the management structure as a whole. By appointing two existing practice managers – Michelle Pratley and Amanda Bone – to work part time as PCN strategic managers, we were able to recruit a PCN IT and business intelligence officer.

We also had to align our IT as the practices were on different clinical systems, so the Three Harbours practices migrated from Microtest to EMIS – which was much appreciated by the Bosvena team. 

Despite the challenges of the footprint, being a PCN has benefits in terms of additional funding and the additional roles reimbursement scheme (ARRS) roles. We have hired 12 new full-time-equivalent members of staff. We now have a team of three pharmacists and two pharmacy technicians meeting the requirements for structured medications reviews and also supporting care homes, managing medicines safety, handling prescribing incentives, medicines reconciliation and community pharmacy integration work. This has had a significant impact on workload and also quality improvement.

Being able to employ new roles at a scale where they make real impact is great. We already had a pharmacist and paramedics in some practices. With expansion comes a more consistent service level. 

PCN power

Also, as a larger organisation, we have felt able to take part in larger health improvement projects. We are one of five PCNs in Cornwall working with the Complete Care Communities Health Inequalities national team to tackle health inequalities in our learning disability population using a community integration approach. We are also one of three PCNs using population health management with the help of Optum, a private healthcare company. 

With our neighbouring PCN in North Cornwall, we set up a Covid vaccination service using our community hospital site – this involved two PCNs and 10 practices, including two that were not in a PCN.

The less tangible benefits have been felt from working more closely with neighbouring practices and supporting each other through the pandemic. We had regular video catch-ups for the practice management teams and established a PCN strategic managers group. This continues to meet weekly. We also have shared support for the interpretation and implementation of procedures and guidance, sourcing PPE, triage models and IT.

This supporting culture goes further than our own PCN. Before Covid, the Cornish CDs were already meeting on a monthly basis to share PCN development ideas and tackle wider issues of concern to PCNs. With the crisis, this group met remotely twice a week in the early days, forging strong bonds and laying the groundwork for what is now an effective and cohesive group. This, plus links with others such as the LMC, has helped the rest of the system in Cornwall hear the voice of primary care as we are able to speak with a united voice as we understand each other’s challenges and views.

Estates challenge

Currently, space is our biggest challenge. The practices are woefully undersized. There are plans for building projects but in the meantime we have had to fund leases on private office space to accommodate the extra staff and the new space is already full. We think the network DES should better reflect the increased number of staff employed.

Supervision and development of new roles is another challenge. Though the ARRS roles have been a welcome development, we have needed to identify a way to free up GP time to train new recruits. We currently fund a session a month for a GP for each of the ARRS roles we employ through the PCN development fund.

IT is another challenge. Our clinical systems have not developed with the pace of change in practices. Some of our ARRS team operate across the PCN, such as our three pharmacists, two pharmacy technicians and the two paramedics performing home visits for the Bosvena practices. The workarounds for shared record access are clunky and are inhibiting further integration. A similar but more marked problem exists with our efforts to integrate with our community services. A shared clinical record would be a strong driver of change.

We are also currently debating the pros and cons of incorporating.

Thoughts on the future

We have tried to view the PCN contract under three broad themes. First, to support existing GMS, to shore up an increasing fragile general practice. Second, to deliver enhanced care to patients through the national PCN service specifications. Finally, to operate at scale to tackle locally determined issues, for example, to redesign diabetes care or tackle health inequalities for our learning disability patients. 

A limitation is the restricted nature of the roles and the lack of funding for management. If PCNs are to achieve greater service redesign, they will need management and project support, but this is not currently funded. We have employed a data and IT support role, but additional project management support will be essential for sustained development. 

For the coming year we will be focusing on delivering the health inequalities and population management projects. We will need to embed our latest recruits, two clinical care co-ordinators, who will work with our two care-home nurse leads and the wider primary and community team involved with the care of the frail elderly. This will be key for delivering the new PCN service specifications that are due later this year and improving integration with our community teams. Embedding the other ARRS roles already employed is an ongoing task. 

Our clinical projects include integration with secondary care, working with our community teams to reduce duplication in home visiting and progressing our work with care homes beyond the service specification.

There has been a lot to learn during these first years. Our main thoughts are: that practices are far more alike than the few differences we are prone to focus on; it takes time, lots of time, to embed changes; and while it’s been a positive to have these new roles, introducing them in rapid succession is hard. But with support and collaboration between practices in the PCN and in the wider network of PCNs, primary care can be a strong force for positive change for patients.