PCN clinical directors joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss working at place level
Dr Reshma Syed, joint clinical director (CD) Sittingbourne PCN, Kent
Dr Robin Harlow, CD Gosport Central PCN, Hampshire
Dr Riz Noor, CD West Enfield Collaborative, London
In practice
Victoria: What is the current status of work at the integrated care partnership (ICP), or place-based partnership board level for your PCN?
Reshma In the partnership board they’re looking into the health inequalities of the area. There are various projects being undertaken in population health management (PHM) and also on developing PCN networks. There’s also work on secondary care trusts and their issues. Other proposals that are being developed include setting up diagnostic hubs.
In our area – the Medway and Swale Health and Care Partnership Board – we’ve got nine clinical directors (CDs). I was elected to be the representative, so I sit on that board. There are other boards that require PCN clinical directorship, which is the clinical, professional and advisory board, which I also sit on. That’s probably more of use to us as PCN directors because we’re in touch with the plans on ground level – patient management and healthcare needs.
Robin I’m not directly involved within the ICP board but as a group of PCNs we’ve got a CD representative in different work streams. These work streams include urgent care and community mental health. More recently we’ve been looking at some of the transformation [work], place-based care, health in communities, and then health inequalities and PHM. That’s a large piece of work we’re undertaking at the moment.
Riz We’ve got very good working relationships with all the CDs, and with the community trusts as well, and we’re working closely with the acute trust. We have huge problems in Enfield with deprivation. Enfield’s a borough that is divided in two. East Enfield has huge deprivation problems and west Enfield has a very elderly population. On the east side, the acute trusts are really struggling with workload, A&E attendance and things like that, so we’re working closely to see how we can support the acute trust in managing that, how much can be taken up by general practice, how we can provide input into urgent care centres to support that system. Health inequalities are a major part of the discussions at the moment.
Victoria: Robin, do you feel like you’ve got a link to the ICP?
Robin We have regular clinical leads meetings. We have regular meetings with our primary care director in the CCG, and regular news bulletins and things like that, so we get information passed down. We are engaged and involved in particular projects as they are developed. I’ve had another role where I’ve been involved in some of the transformation work in the trust. But we’re very much a PCN in the PHM [area of work], and that’s probably one of the advantages of working with an ICP and ICS, is that they can deliver projects at scale. We’re one of 11 PCNs involved in a PHM pilot. And they’re doing that at different levels as well – at PCN level, ICP level, and ICS level. Then there’ll be other projects. We’ve got a GP who is interested in digital and is involved a lot in that. People bring their skills to the different work streams that are required.
Population health
Victoria: With place-based care operating on a larger scale, do you see PHM work happening on a larger scale too?
Reshma I think so. In our area we’re conducting two pilots at two PCNs. They will be distributing their findings and these will be escalated. They want to see how that goes before they do that on a large scale.
Robin It depends what can be done at scale and what can be done at a local level. I think that’s always the tension and the challenge with the top-down and bottom-up approach, and ownership, and development of services that meet your local population. As a PCN doing the PHM pilot at a local level, we’re looking at our system data, and working with our partners in the voluntary sector and the community trust, to understand and deliver something that meets that local need. But then, we can use those skills, attributes and tools on different scales, and different scales have a different agenda, and a different drive. It’s multi-level.
Victoria: Do you think the GPs in your PCN are in favour of carrying out PHM as it seems like a large public health task, which is not the traditional role of a GP?
Reshma It’s a workload issue, because obviously there’s great pressure on PCNs to do lots of different types of work. We’re being pulled in all sorts of directions, and this is a massive piece of work, which is why it’s only being conducted as a pilot, because a lot of the issues in these practices could be representative across the area. This is why it’s not been done at scale presently.
Robin As GPs and as a PCN we are very much at the heart of our population and delivering population healthcare. General practice is not just about diagnosing and prescribing. It is addressing those wider social determinants of health and working in partnership to get the community engaged and look for a wider solution to the health of your population and to the NHS. You can’t do that in an isolated manner.
Reshma Being in a PCN has actually given us the opportunity for working a lot more with community providers. We’re having monthly meetings, getting into the crux of the issues that have affected our region for a very long time, and they’re also helping us convey that in the ICP board meetings and in the hierarchy.
Robin For our PHM pilot, we’ve had three sessions now. In our very localised area, we’ve decided to concentrate on blood pressure in the younger population, the 30-50-year- olds, in a phased approach to try to help prevent health consequences later down the line and [look at] how we get engagement with that population. [We’re also looking at] how we address those wider health and social determinants – obesity, physical activity, smoking, which are the other key factors with hypertension. Within our PHM group, as a PCN, we’ve got representation from our patient participation group, our voluntary, public health and the community trust. It’s real partnership. Although we’ve got a very specific health aspect we’re focusing on, we can look at all those wider determinants of patient behaviour and engagement. It’s really exciting to be part of that. The other thing we’re doing is community mental health transformation. That’s been a really good relationship across the PCNs.
Representation
Victoria: Do you think the ICP amplifies the PCN voice at a system level?
Reshma I’m only one representative of general practice on this board, and although I try to convey the message as best I can, I have to appreciate that a lot of these members have a lot of machinery behind them. They’ve got data, they’ve got internal knowledge, and so I can feel like very small fry in this big setup. This can be a huge problem and it is the worry going forward with the development of the ICSs. Is that view going to be watered down further, or will we have any direct connection to the ICS? The way they’re setting it up, [at the moment mandates] we’re only going to have one representative on that.
My real worry is that healthcare requires a lot of clinical input and that seems to be diluted. For example, we’ve got a clinical professional advisory board, and with the restructuring they tried to get rid of it. So, there wouldn’t be a clinical input whatsoever. It’s only by standing up for it and having people say, ‘Well, no, you do need clinical oversight on all of this,’ that it was maintained.
Victoria: Does your Integrated care partnership (ICP) have a representative at ICS level yet?
Reshma No, and it’s not very obvious how that selection’s going to be made. I don’t think it will necessarily be a clinical director (CD) from a PCN. It could be any GP.
Robin We have a number of ICPs that feed into our integrated care system (ICS). Each of those place-based boards has a GP CD, ours isn’t a PCN CD, and they then represent the ICP in the ICS. Our ICP has a PCN primary care clinical lead, but I am not aware that this role is replicated in the other ICPs and it isn’t represented at the ICS.
Riz Ours is a slightly bigger system because we have the North Central London (NCL) ICS, or currently the NCL CCG, so our five borough CCGs combined to become a CCG, and that’s where the ICS will sit, and each of the boroughs will have their own footprint within that. The system will be quite large and it’s unclear how much of a clinical voice from general practice will be on that board and how can it represent such a large group, as each of the boroughs have very different needs. How do we keep that place-based partnership in the boroughs as well as at the NCL level, to meet the individual needs of each borough? The whole idea with the PCNs was to meet local needs and small was beautiful. Now suddenly everything has changed, and getting away from that. That whole bottom-up approach… we might start losing some of that if it’s coming from above. We need to build up trust that we’re all doing it for the same reasons, and I feel that there’s a risk that we might lose some of that trust and that ethos of equal partnership. It feels as if it’s in the balance, and that the GP voice might be lost.
Victoria: How worried are you that the foundations you’ve been laying as PCNs are being undermined as the system develops?
Riz There is a concern. We’re trying on a borough level to make sure we still work collaboratively and have a distributive leadership model where different PCNs can say, ‘I can do this’, and we learn from each other. If one PCN has a greater need, we try to focus some of the funding towards that site.
As I said, in the east of Enfield, we have a real issue with inequality, so we say, if that’s where the need is, that’s where the funding should go. Having that sort of relationship is easy when there is trust behind it, but as it gets bigger and bigger, [there is a]worry that those decisions will be taken out of our hands and I’m not sure we’ll get the same results at the end.
Victoria: What’s the danger of the ICS not listening to the PCN voice?
Reshma It’s a huge concern, because the ICS for Kent and Medway will cover 42 PCNs. CCGs have amalgamated into that one Kent and Medway CCG, and already we’ve noticed they’re a little bit more distant from us. We’ve lost a bit of that knowledge. Even though we’re all Kent, we all have slightly different issues. There are more deprived areas, such as in Swale and Thanet, so [it’s difficult for the ICS to make sure each region is heard and not treated unfairly]. I’ve always said in our ICP board, ‘Please, what are the discussions with the other [three Kent] ICP boards?’ We need to be more collaborative so that we will have some kind of positive outcome.
Robin It’s such a difficult challenge. I was involved in another project before looking at the equity of services across the whole of the ICS, instead of piecemeal at ICP level. Historically, we’ve had four or five CCGs commissioning and funding individual services slightly differently, which has led to inequity of services. We have the advantage that the ICS can give oversight and say, ‘these are the standards we expect across the entire ICS. This is the best evidence approach’. But how [should that be] delivered at a local scale and where [should it] be done? The ICS is about being able to channel that resource [alongside] wider oversight and outcomes, rather than saying, ‘This is specifically what you must do in this area, and we’re expecting you to deliver this outcome at X, Y and Z’. It’s tools they are giving us to respond in a local way and have local ownership and autonomy in the ICP or at PCN level. As an individual PCN we are very small. We’re lucky that we are, but we’re trying to bring [even smaller units like] individual GP partnerships together to work as one PCN and have a voice within an ICP and have that voice represented at ICS level. That’s very difficult when there might be an acute or community trust that has a much larger voice. [There is] a huge tension about acute trusts; there always has been, [as long as] I’ve been involved in these sorts of roles. The priority ends up being to support the acute and emergency department or elective admissions.
Acute sector
Victoria: Do the ICPs and place-based partnerships help with this as they involve the acute trust?
Reshma It’s always about the acute trusts. It’s always about crisis point. Now it will be about Covid again, as the cases go up. ‘Please stop admissions. Stop people coming into ED.’ [There will be a] pushback into general practice and an increase in workload, and a workload transfer as well. We did a huge survey that demonstrated how much workload was being transferred from secondary care to general practice, so we’ve got these issues to deal with. The problem is that the funding should follow the patient and general practice does 90% of the consultations, whereas only 10% of the activity [is done] in acute trusts, but that’s not conveyed in these discussions.
Riz The problem is the acute trusts seem to have a louder voice. That catches the media a lot more in terms of the long waiting times in the ED. As a result, the funding will follow. We can have those conversations with the acute trusts, but nothing comes of them because their agenda is very different from general practice’s agenda. And sometimes, it’s hard to have the conversation about how things could be done in a different way in their ED, to get them to grasp that general practice delivers in a very effective and efficient way, and perhaps they can learn
from us.
Victoria: What’s the potential of the PCN working with the ICP or partnership board and what’s required to meet that?
Reshma We have a really good working relationship with them. It’s very difficult to say what could be achieved. It will probably be more of the same. We have our own workload and our own targets to address, and the ICP also is trying to work on that. It all comes down to funding, [time and workforce]. A lot more funding is needed for the deprived areas. We need time to engage with meetings and be able to input our thoughts. We also need the workforce. It’s always these things that we need.
Robin I think [we need an] acknowledgement that outcomes take time to deliver, that there are disparities and different priorities even within one ICP. Acknowledging this will enable us to deliver at an ICP level and an ICS level, along with funding and the sharing of workforce, of ideas of what has worked well and what hasn’t. How do we collaborate as ICPs instead of remaining as fragmented CCGs? And why are we not putting more funding into public health and supporting that?
Riz The main issue for the PCNs is having the headspace. At the moment, we feel like headless chickens going from one thing to another, not being able to give our full time and energy to any project fully. It’s meeting after meeting, and I think all the CDs are struggling. I think there’s a lot of enthusiasm and people want to do the best for both their patients at a PCN level, borough level and ICS level, but I feel there just isn’t enough capacity, and the workload is going up. I think they’re being dragged in to get their clinical work done as well as all the administrative and managerial work. That clinical leadership is struggling just to get the time to do that, and yet, it’s so necessary at each of these levels to have adequate clinical leadership.
My biggest worry for the future is how we will develop future clinical leaders. I can see people at the moment are going to either burn out and step down or are coming close to retirement. How are we going to get the younger generation involved in leadership at PCN level, [partnership] board and ICS levels?
