As the introduction of the latest GP contract looms ever closer, plenty of attention is being focused on Primary Care Networks (PCNs) – the latest attempt by the NHS to bring general practices together to work at scale.
Driving the idea of scale has been an NHS policy priority for a number of years now, for numerous reasons. These include enhancing the ability of practices to recruit and retain staff, managing financial and estates pressures, providing a wider range of services to patients as the population evolves and, of course, to more easily integrate with wider health and care systems. Indeed, the development of super-partnerships, federations, clusters and networks highlight how efforts to work together are already on the table. Now, however, the scale working landscape is changing; this time it’s being formalised by the NHS in its long-term plan and the 2019/20 GP contract. The contract outlines how all GP practices are expected to come together in geographical networks covering populations of approximately 30–50,000 patients by June 2019 if they are to take advantage of additional funding.
Opportunity or threat?
While joining a PCN still isn’t compulsory, it’s clear the NHS is pushing practices down that road. With this in mind, does the PCN push represent an opportunity or a threat to Practice Managers?
A good starting point is the comment made by NHS England’s Acting Medical Director for Primary Care, Nikki Kanani, that PCNs typically need a new style of leader, rather than transferring them from clinical commissioning groups or elsewhere.
Talking to HSJ, Dr Kanani said that different types of people were taking an interest in becoming the clinical director for their network and that she hoped this would bring in new leadership. She said she was “respecting [of] previous leadership, but we need a new style of leadership, we need to make sure it’s collaborative and connected, and representative”, before going on to add that the idea of moving senior clinicians in CCGs to be PCN leaders “doesn’t feel quite right to me”.
She said: “In some areas that might be the right person, but I think that needs to be a conversation between practices as to what is the right type of representation because it is a provider role, not a commissioner role.”
Dr Kanani said PCN clinical director roles were already in some areas attracting GPs who had not engaged with system leadership before.
As one PM pointed out to us, this can create both opportunities and threats. “Change is scary, so you’ll have to lead your team through any transition and learning,” they said. “Plus, there’s always disruption if you have changes of leadership and there’s a danger with GPs that egos will get in the way. I’ve seen GPs around here almost behaving like wild animals as they try to assert their power. Then there are the inevitable process changes as leaders try to make their mark.
“On the other hand, there is the opportunity for PMs to shape those new processes and become a real influencer within the PCN. Especially in practices where processes are done the way they are ‘because that’s how they’ve always been done’, this is an opportunity to make meaningful change for your own good and the good of your team. If you’re ambitious there might also be the opportunity to progress your own position.
“Finally, there may well be the opportunity to ease some of the pressures on you and your team by spreading work across a PCN’s combined team. If you can tap into strengths across the network, it can make for better working, save time and create happier people.”
Hone your role
Writing in a previous guest blog post about partnership working that is well worth a read – click here for more – @virverax, a Practice Index Forum Legend suggested that working at scale can be a positive for PMs. Especially if the opportunity is grasped to hone skills and work like a larger organisation should. In many ways, the opportunity of practice at scale comes from working more like a corporate organisation.
“At a geographically local level there has been a mushrooming of collaborative activities between practices that could not have been dreamed of under Practice Based Commissioning,” they wrote.
- Shared on the day triaging of patients between multiple practices
- shared paramedic home visiting services
- shared primary care mental health triage
- shared first call physiotherapy
- shared practice pharmacy initiatives
“The above are all examples of concrete achievements that would have been unthinkable even a few short years ago,” they continued. “The key to this is a sense that PMs will have to move from the ‘Jack of All Trades, Master of None’ role towards a more specialised skills-based approach centred upon the needs of a wider organisation and having the opportunity to do things that they feel good at and enjoy.”
Another PM echoed those thoughts and told us: “In a PCN we have to become smarter and not try to do everything. That means letting go of tasks, which as a group we’re not good at. The opportunity will only show its face if we let it. We have to think about defined roles and how we play to our strengths and avoid our weaknesses. A manager of the HR department in a big business wouldn’t cover reception or deal with accounts. We have to shift our mentality that way too and truly embrace the partnership and what it brings.”
As we’ve already alluded to, setting up and getting used to working as a PCN provides plenty of challenges to PMs, not least working out structure, governance, reporting and management.
Then there are concerns to do with budgets, income, DES money and how it’s allocated and so on.
“There’s an awful lot of practical admin-based work to sort out when coming together as a PCN, and that’s before you start on the personnel side,” one PM explained to us. “This is, without doubt a threat to our work/life balance and I’m sure we’re in for a busy period given the tight deadlines imposed by the NHS. However, the best way I can see to overcome this is to view it as ‘no pain, no gain’. If we can work through the problems and create a more agreeable structure for us, it’ll be worth it, albeit challenging.”
Overcoming the challenges
Another challenge to overcome is the one of rigid governance – and it could be that this is where the support of LMCs come into play. Commenting for an article in GP Online, Londonwide LMCs chief executive Dr Michelle Drage said she didn’t believe ‘rigid governance’ would be vital to run networks. “I think you have to have an attitude within the network supported by the CCG that isn’t anti-collaboration. And I think form should follow function with networks.
“If we find that practices are being performance managed either unrealistically or unfairly then we will be taking a view at on how that is done. We will support the practices that need support and we will try and measure the system that is driving that performance management to make it fair.”
Then there’s the problem, as touched on briefly above, of setting up PCNs within the timeframes detailed by the NHS.
King’s Fund senior fellow Beccy Baird, said: “The timelines attached to the development of PCNs are extremely ambitious, and the scale and complexity of the implementation challenge should not be underestimated. While many practices have already been collaborating in federations, clusters, and networks, the general practice contract places collaboration on a more formal footing. For example, primary care networks will require a single bank account and a legal agreement between the practices for the delivery of services.
“In addition to this formal legal agreement between practices, networks will be encouraged to get the sign-up of wider partners, including community, mental health and voluntary sector providers. All the evidence shows that successful working at scale requires deep trust, strong relationships and a shared vision and values. As a result, embryonic networks may well need significant support to develop and sustain the kinds of working relationships that will be required, both between the practices in a network, and with the wider system.”
That means practices will have to work hard to build effective working relationships and trust with wider community services, which will take time. Where you find that time from is certainly a challenge.
Overall, PCNs provide both opportunities and threats to PMs but, just maybe, the positives may well outweigh the negatives. Many of the threats and challenges to PMs are more short-term, while the opportunities could well bring benefits in the long-term.
As Virverax wrote in their blog, “After many years as a PM there is a glimmer of hope for me that, as part of a larger cohesive single entity, we are now more in a position to face down threats from a position of relative strength.” Let’s hope that proves to be true for PMs everywhere.
What are your views regarding the impact of Primary Care Networks on PMs? Can you see tangible benefits or is it just another misguided attempt by the NHS to change the structure of primary care for the worse? Let us know by commenting below or take it to the Practice Index forum thread here.
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