The NHS 10 Year Plan has very little detail on the future of PCNs. Emma Wilkinson looks at how clinical directors should prepare for what’s ahead.
In the Government’s long awaited and much trailed NHS 10 Year Plan there was only one short mention of the primary care networks.
Existing PCN footprints would be the ‘springboard’ for a new type of contract to create ‘single neighbourhood providers’ serving around 50,000 people, the plan said. A second contract for ‘multi-neighbourhood providers’ on a larger scale of 250,000 population allow for working at scale.
The ‘ambition and direction of travel is very much welcome’, says Dr Shanika Sharma clinical director of West One PCN in Barking and Dagenham. Yet there is much ‘clarity’ still needed.
She was ‘reassured’ to hear in a recent webinar with NHS England primary care director that PCNs were very much part of the plan.
As chair of the local GP Federation – Together First CIC – she is now trying to work out how primary care can navigate the new contracts while knowing she does not yet have the answers to many of her colleagues’ questions.
For Ruth Rankine, primary care director at the NHS Confederation the plan is a ‘real opportunity for primary care’ with some very positive announcements including a review of the Carr-Hill formula.
‘I think the direction of travel seems to be evolution rather than revolution. And I think there seems to be lots of scope for local flexibility and for local leaders to determine what they think is right for their area, which we're really supportive of.’
But it has to be acknowledged that a lot of PCN clinical directors are exhausted and have had to deal with a huge amount of flux.
‘It is important to caveat that we are asking a group of leaders that are often going above and beyond to massively rethink, in some areas, how they're looking at collaboration.’
In Dr Sharma’s view, the role of PCNs should remain transformational with the federation looking after the transactional, reporting and contractual requirements. ‘This synergy of operations works really well for us,’ she says.
It was also clear from the webinar that if GPs don’t step up, others – including hospitals - could swoop in and that could even get a bit ‘ugly’, she adds.
Dr Stewart Findlay, PCN representative for County Durham, was also somewhat reassured by Dr Doyle’s assurances but says the new contractual landscape ‘looks a little messy’.
‘I would expect there'll be a move towards making PCNs into one of these new entities – the single locality provider – who can employ staff on behalf of their practices.’
The federation in Durham Dales already works like that with clinical director of the PCNs on the board, he adds.
Where he has real concerns is the proposals for hospital trusts to take over neighbourhood contracts where GPs have not stepped up.
‘I think PCNs and federations would be wise to look at the multi-provider model, because if they don't take up this challenge, it's likely that our foundation trusts will.
‘If that happens, I think the partnership model and the way that primary care is run at the moment is at risk. Certainly the feeling amongst our federations is that they that they want to look seriously at this.’
The example cited in the 10-year plan of Primary Care Sheffield is a pretty good model which has the advantage of scale and something others could emulate, Dr Findlay says. Working out the best payment mechanisms to support this – as alluded to in the plan – will be vital.
‘Primary care is pretty fleet of foot, so we could get something up and running pretty quickly.’ The issue will be having contracts that support sustainability.
There are many areas including diabetes, dermatology, rheumatology, gynaecology, frailty where primary care could very easily offer services. In Durham they have long-standing community diabetes and ECG monitoring services. Yet this year both were earmarked for potential closure.
Dr Sharma also points to a dermatology service run by GPs with special interest in north east London that has been told it has become too expensive because it has taken on so many referrals.
‘You think hang on a minute, this goes against the ambition of bringing more services in the community,’ she says.
Dr Findlay adds: ‘I see the survival of PCNs, or whatever they're called in the future, and survival of the partnership model will be dependent on our clinical directors and our federation working together to establish themselves as multi-neighbourhood organisations.’
The implementation programme announced last week does give PCNs a bit of a steer, says Rankine. The focus right now should be on relationship building, she adds.
‘Do you know who your population health leads are, your social care leads within your local authority. What is your relationship like with your provider of community services.
‘I think there's a really unique role that only primary care can lead on in terms of the construct of neighbourhood health, in terms of risk stratification and population segmentation.’
Dr Saul Kaufman clinical director of St John's Wood and Maida Vale PCN says shifting to align with the 10 Year Plan may be more tricky for PCNs who have been very medically focused, he says.
‘If the PCN has always seen themselves as the neighbourhood delivery vehicle, which includes the local authority, voluntary sectors and not just traditional general practice, then they're already doing it, regardless of whether it's one PCN or a PCN grouping.’
But the uncertainty around what exactly the model and funding stream will look like does bring with it some anxiety over loss of ownership, he adds.
Beccy Baird, senior fellow in health policy at The King’s Fund agrees ‘it is really clear that GPs are going to have to step up’. She also points out the contract landscape looks messy but that is not necessarily a problem because it needs to be flexible.
‘But I don't think that acute hospitals in very many instances are the right people to be running neighbourhood health services. They don’t have the same understanding of community.’
ARRS staff will be at the heart of a lot of those neighbourhood teams so it would be an odd concept for PCNs not to be fully integrated into any neighbourhood provision, she adds.
Dr Kaufman says it is likely that ARRS staff will be deployed at practice, PCN and neighbourhood level, which is what they do already in Westminster.
How ARRS funding, deployment and supervision is going to work in a wider NHS system is just one of a myriad of issues to be unpicked, Baird says.
Her biggest fear is there won’t be the support for primary care leadership. ‘I'm very worried about the lack of people within ICBs, either with the skills and the expertise or just the bodies, because they're getting rid of so many people.’
The 42 pilot sites will be interesting, she adds. ‘They have to be nominated as a group of providers. So if a foundation trust wants to provide it, the GPs in the area have to support them.’
Community diagnostic centres are likely to be a key part because at the moment there's issues with them being too remote, often set up in secondary care. If they’re not part of the plans they will end up as ‘total white elephant’, she says.
Right now the priority for clinical directors should be making sure local relationships are strong, she advises. ‘GPs, have to be ready for this, they can't just wait and let it happen to them.’
In essence, primary care is very well placed to deliver neighbourhood health services, or certainly to be a key pillar in that that relationship, Rankine says.
‘For PCNs right now they should focus on looking at the parts they can deliver and where there are gaps, looking at other primary care, at-scale organisations that can help them, or equally, look at the role of other providers,’ she adds.