PCNs and the neighbourhood NHS

Victoria: Can you give a brief outline as to whether your PCN is leading, managing or part of a neighbourhood team?

Sian We decided as a PCN to take over leading the integration, but that’s not been without controversies in the sense that our community provider would also like to lead on integrated neighbourhood teams (INT). So, it’s about working out how we collaborate successfully over that.

What we’ve discovered is that you need to look at the patient journey. The functionality of the INT is very dependent on an intimate knowledge of the patient group and also having the time and access to the records to be able to formulate personalised and proactive care planning.

Shanika Our PCNs and federation are interlinked – the federation has grown services across the borough for all six PCNs for things like enhanced extended access. From the start, one of our core ambitions was to bring neighbourhoods together so rather than employing social prescribers as a PCN, we subcontracted to the local authority and all six of our social prescribing link workers were employed across Barking and Dagenham and the six PCNs.

In terms of our role in INTs, I’m a bit concerned. Before PCNs, Barking and Dagenham was split into three localities, and the local authority and our community providers still work in localities. They want to go back to that model for INTs, but that doesn’t align with the PCNs.

At the moment, general practice and PCNs aren’t being involved in the INT conversations – not just public health and the local authority but, also, unfortunately, not by ICB colleagues who are place-based – which is making it really concerning.

I think this is the first time in 20 years that I can see people coming together with a really good intent to get things sorted  

Dr Binodh Bhaskaran

Nick We’ve had an anticipatory care model roll out across Kingston and Richmond boroughs, which is collaborative. So, in some ways, that very much sounds, smells and looks like an INT. That’s largely funded by the acute trust because of the large return on investment it’s shown on unplanned admissions.

In terms of what INTs are now, one of the big challenges is that our PCNs don’t align with neighbourhoods. Geography is something we’re grappling with and there is real variety in opinion, which is the challenge, really.

How the neighbourhood team will function, I think it depends on the projects. For some projects, we will do it across the borough or across place. And we will do it PCN by PCN because it’s very much a local community partnership with the voluntary sector.

Amit We’ve got an emerging strategy around INTs and how they might be shaped according to our patch because in my role as place lead for Berkshire West, we wrote a strategy paper on what ‘left shift’ looks like and the INT role in that. We did it to get senior executive level buy-in from the trusts and the ICB.

So, generally, we’ve got a good consensus, and now we’re just getting into the details of exactly who’s delivering what.

In terms of strategy and the leadership of the INT, that’s at the three local authorities – so about 150-200,000 – with more localised delivery happening in each PCN area.

We’ve got a complex geography –  a total population of 600,000 in the place, but three local authorities within that. And their role is critical if we are truly trying to get out into neighbourhoods and move into a more preventative and proactive space.

All the successful INTs have had a system integrator, bringing together other providers and giving accountability. Essentially, we feel that general practice is in a prime position to do that in some areas.

Leslie From the beginning, I’ve chaired our health and wellbeing board, which involves local authority, dental, voluntary, public health and our acute provider, and we have a monthly meeting. We’ve had a review of the health needs of our local population, and drew up some priorities. And we’ve been setting up and working as a community to look at how we address those across the sectors. We do have buy-in from the local universities as well, from academia, and we’re ensuring we get that input as well.

Our GP Federation is one of three in our area and we meet to discuss some of these bigger areas with our ICB. We think we have a good relationship with them. We’ve recently formed a collaborative between the federations to start offering more community-based services such as ADHD monitoring and spirometry.

Binodh We are pushing the agenda of INTs a lot.

Last year, the main focus was on developing provider collaboratives  –  trust level, community level and primary care level – and we have a board now, which meets every two weeks for primary care.

I’m leading on our INT – or ICT [integrated care teams], as we call it – and it’s based on the local authority geography. Luckily, we are two PCNs.

One thing that our ICB did to promote ICT working was to give about £40k to each ICT across Sussex to have a GP lead, supported by a manager or admin person, for two years to make sure that these structures are built up.

Our ICT steering group has come up with an ICT core offer and each ICT has got to work towards that. It’s a road map to see how population health needs are met and we deal with them.

I think this is the first time in 20 years that I can see people coming together with a really good intent to get things sorted.  We are agreeing on loads of work together with our pharmacy colleagues. For example, we are looking at how we work together in vaccine delivery next autumn and we’ve done a brilliant piece of work around proactive care this winter.

Victoria: What do you think neighbourhood health care will be focusing on in your areas?

Leslie The priorities we drew up were teenage mental health, death and dying, dementia and loneliness and an overriding arc of carers. We wanted to choose the priority areas that are important to our community and then work as groups. So, we have done various group events in the community – in non-medical settings, such as community halls – with a combination of VCSE and medical, both general practice and acute.

For example, we had one on preparing for winter if you’ve got a respiratory condition. It’s been done as a group consult and we’ve broadened the offer by inviting along housing, mental health, and physical activity. It’s about reducing system pressures by working together.

Binodh We have lots of strands. One is the proactive work with community services. The second is falls prevention work, which we’re doing with the frailty practitioners, community rehab teams, consultant geriatrician and the PCN workforce. Frailty care coordinators and social prescribers work together to prevent falls. It’s not to see patients who’ve had a fall, but before they fall. We have developed a frailty prevention tool that we’re using to identify these patients and proactively contact them.

We are writing a document at the moment around how we can do chronic disease management in an integrated fashion. We’re working to create an integrated care model in the community and applying the rules of ‘make every contact count’ to make sure hypertension is managed properly in our system.

And we’re looking at how urgent treatment centres are going to develop. The federations are working with the acute trust to deliver that particular part of the service.

Nick I already mentioned the anticipatory care work we’re doing. We’re also focusing on frailty as a priority.

This is a risk stratification tool across two places that identifies people with a rising risk – not just high risk, but a rising risk – that identifies people for our MDTs to work with. The MDTs involve the community provider, the frailty teams in the acute trust and primary care.

And then we’ve got care coordinators who take on a relatively small cohort of vulnerable and complex patients and manage and streamline their care better. It’s shown huge benefits in reducing the use of acute trusts, 111 and GP appointments.

Then there’s screening. We have a very high Chinese/Korean community who’ve got a high risk of hepatitis, so we’ve been doing proactive scanning for those high-risk liver patients across the borough with a mobile van. We’ve also been doing cancer screening for a number of things.

Carers are also a big area of focus. A significant number of elective admissions are because of a failure in family care arrangements. So, we’ve got funding for a carer liaison service within the hospital as well as community carer events that we run regularly. These provide legal advice, medical advice, help with streamlining care and respite.

It’s a really interesting way of working. It’s been phenomenal in terms of proactive care and shared risk

Dr Sian Stanley

Amit We have a programme of community wellness checks, which goes across the region involving all 17 of our PCNs. This is a collaborative piece of work between the federation, local authorities and trusts as well as voluntary sector organisations. The checks are largely done by the voluntary sector, although the acute trust do send some of their nurses to be involved as well. They are holistic checks – glucose, cholesterol, blood pressure, AF and also social prescribing, mental health and support with life issues with Citizens’ Advice available.

It’s delivered in the community, but the information goes into your EMIS clinical record straight away; it’s all read coded and properly aligned to the QOF codes. That means the general practice gets a notification that a new record has come in and what follow-ups are required.

Sian For population health management in terms of unplanned admissions, we’ve looked at mental health and drugs and alcohol – not just direct intoxication, but the consequence of being drunk, broken ankles and such like. We used our integrated information to create drug and alcohol services. We have mental health MDTs so, depending on the patient, social care will be there. Sometimes, even the police will be there if it’s appropriate and we’ve got the patient’s permission.

It’s a really interesting way of working. It’s been phenomenal in terms of proactive care and shared risk. And I think from a GP perspective, one of the nicest things has been the ability to discuss with senior colleagues about how to manage some of these pretty tricky people. And when we have sadly had deaths, we’ve all been able to work together to support each other.

Shanika We looked at the most vulnerable populations, which are patients with learning disabilities and serious mental illness. We invited people who hadn’t attended their general practice for a review. We had 11% of patients who hadn’t been to their GP surgery in five years come for a checkup. We created a one-stop-shop where tests could be done, such as blood tests and ECGs. We did joint consultations – MDTs with our community colleagues – and had social prescribing, advocacy services and exercise services. We had everybody there for people to talk to. It was great and we’ve demonstrated impact.

This is the kind of thing that we should be doing at neighbourhood level to support our most vulnerable. But who’s going to fund it?

Victoria: That leads us onto the challenges – what are the challenges you face in this space? And is there a sense of risk to PCNs?

Nick The challenges are the funding streams. The proactive, anticipatory care work that we’re doing for frailty is funded through the BCF (Better Care Funding) and the acute trust provides funding of £500,000 a year to run it. So, it’s not actually business as usual, normal, everyday funding – it’s short-term funding rather than core. It’s something that we’re having to prove year in year out, which is a challenge.

We’re increasingly moving acute trust outpatient work into community clinics. It’s the usual suspects – dermatology, neurology, vasectomy, urology and we’re also moving into cardiology and lipids.  That’s mainly federation-led and something we’ve done for some time as an ICB commissioned service, but that’s all been decommissioned from the ICB and moving into a contract. Increasingly, we’re looking beyond it being just an outpatient thing and looking to expand it along with community colleagues and the voluntary sector. But the challenges are the frailty of the contracts.

Binodh  Yes, the main barrier is contracts because we are sticking it on to the older contracts and there’s a constant battle between general practice and community service about who will prescribe, who will investigate, who takes responsibility and so on.

We’re working on improving the contracts now. The local authority and general practice have agreed to lead together at this point in time.

One anxiety that we have is the future of PCNs. I think PCNs will start to slowly disappear because there’s a big push for the ARRS funding to be used at practice level, which I think is counterproductive to the whole PCN agenda about networking and coming together.

Sian It’s the PCN resource and working at scale that has probably had the single biggest impact on integrated neighbourhood working. It’s taken a very traditional view of what primary care is and flattened hierarchies. Getting an understanding of the social needs of our population has only happened as a result of PCNs. As an individual practice, we could not form that integrated neighbourhood health care. Everything we have done has relied very heavily on the shared resources of a primary care network.

The other thing is our ability to be able to sit at the table with these big organisations. There’s no obvious interface between primary care and an organisation like an ICB or the Department of Health and Social Care because primary care is fragmented. The BMA is not the interface and neither is the Royal College. And even though we have a really robust federation and a robust collaborative, we’re minnows when you’re working with massive organisations with a huge infrastructure. And a big issue for us is estates, without doubt. We’ve run out of rooms – end of.

Leslie  The issue of rooms could be resolved if we were appropriately resourced because there are lots of community venues and the sort of work we’re talking about doesn’t require CQC-registered rooms.

There’s a lack of vision as regards to giving us an opportunity to work for three to five years to prove that this can work. And we need to remember that we also have a day job – we need enough time during the week to look after our patients and our staff and look after ourselves. In a trust, there’s a medical director who does this full-time. I’m medical director on a Friday morning and I’m clinical director on a Tuesday – every other day, I’m a doctor. So you can’t be as quick at responding as compared to those big organisations.

We’ve got a great federation, but again, we’re a small team running on a very tight budget. So, if we want to play big, we have to have money to be able to say, ‘Right, we’re ready. We can play big, but I need more than two days’ notice for this and you need to realise that I’m in clinic until Friday morning now’.

My biggest concern is that INTs are going to pose a risk to PCNs and dismantle what we’ve worked so hard to build over the last few years

Dr Shanika Sharma

Shanika Funding is the biggest issue. In our patch, we haven’t heard about any funding streams coming to help support INTs.

My biggest concern is that INTs are going to pose a risk to PCNs and dismantle what we’ve worked so hard to build over the last few years. That applies to health inequalities as well. What we don’t want is to have three different INTs in my borough which might introduce health inequalities within the patch.

The other thing is workforce. The ARRS workforce is fundamental to supporting PCNs, general practice and patients. If these roles are going to be asked to work across a wider footprint, that’s going to be a huge challenge. At the moment, recruiting people to work across seven practices is difficult as a PCN. If I’m then asking them to work across multiple organisations, that’s going to be very difficult.

I think there’s a risk that general practice is going to suffer because a lot of the core GMS workforce funding has gone into ARSS funding. If PCNs are being dismantled, the workforce funding should go back into the GMS contract because otherwise practices won’t be able to survive.

Working at scale sounds very good, but a lot of our GP practices are still operating from very small premises. So, there needs to be some sort of investment into estates. And if we are looking at working across organisations, we’re going to need information sharing. At the moment, we’ve got multiple different systems being used so that integration needs to be looked into as well.

Amit The interface between us and the hospital continues to be a challenge. And the strategic commissioning piece is a real challenge. We are struggling around strategic commissioning, contracting and procurement. People have talked about how we’ve got a most suitable provider procurement model, but very few ICBs are using it because of the fear of challenge from private providers. And that means we’re spending a lot of time in procurement when we could be spending that time developing some really good, integrated clinical services.

On a system level, one of the problems is actually taking funding out from the acute trust. We talk about the shift, right? But actually making that shift is quite difficult because you can switch activity out in the community but how do you take the cost out of secondary care? Unless there’s a ward you can shut or a staffing resource you can cut, where’s the cost going to come from?

We’ve got an overly medicalised model. There’s a lot of reliance on doctors, on clinicians, and we’re not encouraging the public to take enough responsibility or supporting them to be proactive in their health. That’s part of the reason we have the problem of demand.

Victoria: Finally, what do you hope for in the future in terms of neighbourhood teams?

Sian When you’re looking at contracts and bidding for contracts, my hope would be that you get into lead provider models in the future. So, the ICB contracts are properly using primary care as the lead provider, but in collaboration with other organisations and those relationships are facilitated properly.

And it goes back to there being a lot of GP pessimism about what’s going on at the moment. Not all GPs want to take on this work and there’s an ambivalence, I think, from our colleges and the BMA.

I think that we have to be supported to go into this brave new world because it’s very different. And I would just say that, you know, throw PCNs away at your peril if integrated neighbourhood working is what you want as a system.  To subsume that money back into primary care to make it more individualistic is just such a retrograde step, in my view.

Binodh I think the key thing now is relationship building – there is a big gap between us and secondary care teams and community services. I’ve been asked to look after East Sussex to improve GP engagement as my role as the primary care provider collaborative lead, which means that I speak to all the individual leads and GPs. We’re doing that to bring the trust back. And the only way we can do that is by improving the interface relationships. So it’s trying to put the parts of the jigsaw puzzle together.

We have to find ways of working innovatively and we probably have to change the way we work again. Covid has shown us lots of ways to improve our working. We are relying a lot on the councils – they’ve got loads of estates that we’re using at the moment, places where you can develop the clinic space and MDT working.

Our model is too medicalised so I’d hope to change that by building a voluntary infrastructure in the community so we have a genuine alternative to normal mainstream NHS care

Dr Amit Sharma

Nick The problem is short-termism, the uncertainty around the future of PCNs, the scale issue and the lack of clarity of any long-term vision from the centre. Because, you know, being an early adopter is great, but some of our colleagues think, ‘Well, okay, that sounds good for a year. But do we want to be employing people on permanent contracts on a large scale when we don’t know what’s going to happen to them in March 2026?’ And that’s a real challenge.

Amit The community wellness check programme that I mentioned before exemplifies what INTs should be doing. Through this method of working, we are picking up record levels of diabetes, high cholesterol, high BMI – higher than you’d expect in population prevalence because these patients don’t come into general practice.

The first check was January 2024 and, by the end of June, we’ll have done 10,000 checks.

Every part of the system that’s involved is paid for their element of the work; local authorities commission the voluntary sector to deliver the checks and there’s a locally commissioned service to support practices for the work that they’ve got to do.

So that, really, for me, is the future and what I’d like to see be developed further. Our model is too medicalised so I’d hope to change that by building a voluntary infrastructure out into the community so we have got a genuine alternative to normal mainstream NHS care.

This roundtable took place on 5 March  prior to the announcement NHS England being abolished and ICBs being required to make 50% cuts.