England General practitioner

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Primary goals

Issue 12 The Doctor
SPENCER: 'Have I made a real difference to any of these people?'

For GPs facing a spiralling workload, it is hoped primary care networks in England will help tackle long-standing, systemic problems. Peter Blackburn meets early adopters of the principles behind them

‘It’s the end of the working day and my brain was absolutely frazzled,’ GP Mark Spencer recalls, reflecting on his working life before he and colleagues took matters into their own hands.

‘It's something collaborative to try and support general practice’

‘Many clinicians will look back on their 30, 40 or 50 patient contacts and wonder: have I made a difference – a real difference – to any of these people? How can I make a difference in 10 minutes when their needs are so complex? It feels like I might have just as well not been here – I’ve done nothing for nobody.’

Those questions, asked after another 10- or 11-hour shift, will be grimly familiar to many across the profession. A spiralling workload, with increasingly complex patients in a resource-poor environment is an equation that is only likely to lead to dissatisfaction and burnout.

There have been efforts to rebalance this equation before. But most have been clumsily forced from the top down and without the resource or clinical engagement to make them worth more than just the latest empty words in another NHS plan for the future destined for the shredder.

 

Driving seat

It is into this thorny world that PCNs (primary care networks) arrive in England, with remarkably lofty aims: to put doctors in charge of the local design of care, kick-start population health in local areas, and tackle the long-standing systemic problems crippling primary care.

PCNs are groups of GP practices, usually covering between 30,000 and 50,000 patients, which will collaborate to deliver services in a more integrated way, while also allowing GPs to retain independent contractor status.

GP practices will hold the PCN contract and be the ‘core members’ of the network but may ultimately invite other organisations to join, in a bid to bring local mental health, community and social services together. Each network will be given extra funding for this, as well as money to extend access hours for patients.

The deal includes PCNs being reimbursed for hiring a clinical pharmacist and social prescriber – and will next year pay for the additional roles of first contact physiotherapists, physician associates, and primary care paramedics, with PCNs deciding which roles to recruit based on their population needs.

 

GPs centre stage

Fundamentally, the ideas behind the move seem sound: GPs know their localities and patients best – so why not put them at the heart of planning the care they need, while also working at a scale where they may be better able to afford and accommodate staff and services for their population.

And while the networks aspire to improve care for patients, they are also intended, first and foremost, as at least part of a solution to the continuing systemic problems in primary care. Recruitment and retention difficulties largely stem from unsustainable workload and inflexible working arrangements – PCNs, which are promised cash for multidisciplinary teams who can take unnecessary workload from GPs, and may be able to offer more flexible working arrangements across a wider area – could be an answer to some of those issues.

Perhaps most crucially of all, these changes aren’t being forced upon GPs. The BMA has been at the table, as part of negotiations around the NHS Long-Term Plan and new GP contract, and is helping to drive the process.

‘We are leading this change,’ BMA GPs committee executive member Krishna Kasaraneni (pictured below) says. ‘This is not something that has been done to us, it’s something collaborative to try and support general practice.

Krishna Kasaraneni -portrait - neutral

‘The way we look at PCNs is as an umbrella and support for practices so they can work together on things they need to do together while maintaining their independence. We have to start looking at things where we can say what is right for the patient, how can we support GPs to deliver that seamless patient journey while also managing workload issues.’

Dr Kasaraneni adds: ‘It’s a five- to 10-year plan with fixed investment for five years. It will rely on many things working in our favour – recruiting the workforce, people getting behind the ethos, and taking small steps rather than giant leaps so the whole thing doesn’t fall over.’

 

Model of care

So where have PCNs come from? Schemes with similar aims have been running around the country for some years as pilots, and, anecdotally, have helped tackle some of the issues GPs face. These are models which seek to link staff from general practice, other NHS services, and the social and voluntary sectors.

One was set up in Durham Dales, Easington and Sedgefield. Rajiv Mansingh, GP at the Marlborough Surgery in Durham, says community services contracts have been re-procured to be aligned to the geography of each scheme and community nursing had returned to GP practices.

Dr Mansingh says: ‘Many key long-term-plan initiatives are already under way, including a proactive population health management approach, rapid community response teams to keep people out of hospital, expanded neighbourhood multidisciplinary teams, social prescribing and joint working with community pharmacy.’

The models became PCNs and now employ social prescribing link workers, an enhanced clinical pharmacist service and a ‘first contact’ physiotherapy role commissioned by the local acute trust and placed within the networks.

 

Risk of collapse

In Fleetwood, Lancashire, Dr Spencer and colleagues have also been on their journey to integration for several years, having been an early adopter of the PCN idea.

The seaside town, once famed for its fishing industry, now has significant health inequalities, poor health outcomes and a much higher than average prevalence of all major long-term conditions, with high rates of mental health issues like depression and anxiety. With workload, and complexity, spiralling, general practice also faced a workload crisis.

‘The system itself won’t make PCNs work – it has to be the guys on the ground doing it’

Just five years ago, only eight GPs were doing the work of 16 in the town and collaboration between the three GP practices seemed the only option to stave off the ‘genuine risk’ of collapse of services in the area.

‘We really did have that burning platform people talk about,’ Dr Spencer says. ‘And despite the best efforts of the NHS, the health of the town by any measure was getting worse and the patient need becoming ever more complex.’

Dr Spencer adds: ‘It required us to think differently and we chose voluntarily to work in a very integrated way, not only across three practices but also with all the other healthcare providers in the town – community nursing, therapy, mental health services and drugs and alcohol providers.’

 

'Lack of hope'

The PCN, called Healthier Fleetwood, has since become something of a model for others to follow. Here, doctors decided to address the systemic issues in general practice and the health of their population at the same time – looking to make general practice a feasible workplace as well as developing a ‘social movement around building hope’ in the town, a place where ‘there has been a lack of hope and optimism for decades’.

The GP practices employed multidisciplinary teams including paramedics, clinical pharmacists and mental health nurses, all of whom were integrated not just into services but also into the physical buildings housing general practice. The PCN also adopted a medicine management hub.

On top of that local residents were assembled to form a committee with access to funding for patients to set up groups, run activities and pilot schemes which could benefit the area – tackling problems such as isolation and obesity. The projects are created by the community, sanctioned by the community and provided by the community. A team of staff are on hand to help set up table tennis and singing clubs (see below).

The good news? Anecdotally, many patients are getting better. They are more connected, happier and healthier.

The bad news? The unmet need in the community – an area which has suffered deeply from underfunding and the collapse of industry – swallows up much of the time and breathing space generated by the proactive work of the PCN. More innovation, and more resource, will be needed.

Dr Spencer says: ‘I am optimistic about the future of general practice – I firmly believe that if a PCN is set up in the right way and it does involve every single health and social care professional in that community and neighbourhood, and residents are equal partners and do have control, I am really hopeful that this model is heaps better than the model that we’ve had which is no longer fit for purpose.’

 

Culture change

While the intentions – and possible results – seem positive, there will clearly be difficulties and obstacles along the way, particularly for practices not used to working together.

‘It’s a big culture change and there will be times when practices fall out with PCNs,’ says Nottinghamshire local medical committee chief executive Michael Wright (pictured below).

‘The biggest thing during these early days has been the expectation of 100 per cent of patients having extended access.

‘That’s been a big difficulty for us – some practices have not done that for years so need their PCN to have a way of delivering it in their name. It’s the first of many tests.’

Mr Wright also says PCNs attract a whole new wave of younger GP leaders and that those staff would need access to continuing leadership and organisational development, as well as suggesting LMCs around the country would have to be on hand to ‘broker’ things wherever surgeries, which have not traditionally been part of local alliances or collaborative work, feel isolated.

 

Human touch

Despite the obstacles, Mr Wright, whose LMC has been encouraging collaboration through a project called Phoenix in the East Midlands for some time, is optimistic about the future.

‘I can see where this could go,’ he says. ‘The system itself won’t make PCNs work – it has to be the guys on the ground doing it – but the LMC feels this is the way forward.’

Speaking at a King’s Fund conference on PCNs in July, NHS England’s acting director for primary care provider transformation Ned Naylor was coy about whether the funding would be forthcoming, despite hailing PCNs as a ‘bold vision’.

‘I am really hopeful that this model is heaps better than the model that we’ve had’

He said: ‘It’s a bit of a case of wait and see… watch this space.’

The issue – unanimously, it seems, agreed upon – is that PCNs are given time. Time to make mistakes, time to build relationships and time to grow. These changes cannot be forced through in a year and then ripped up if they don’t bring instant results.

 

Commitment

GP leaders are committed to making PCNs work and want feedback.

Dr Kasaraneni says: ‘This level of investment and commitment from NHS England has been very welcome – it won’t solve all the problems but it’s a much-needed investment and a real commitment to support general practice.

‘We will try our best to make it work but we need the profession to tell us when it’s not working so we can fix things and try and make it work better.’

Ultimately, the ambition has to be that when GPs such as Dr Spencer reflect at the end of the day, the question is, ‘how many people have I helped?’

As Dr Spencer says: ‘In this new world we have the ability to actually make a difference. And general practice can become an attractive place to work again.’

Find out more about PCNs

Explained: what are PCNs?

 

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