Digital transformation: PCN progress so far

As the potential of technology increases, so will the importance of digital and transformation roles at PCNs. Clinical directors and digital transformation leads (DTLs) joined Pulse PCN editor Victoria Vaughan to discuss the impact and success that the DTL role has had so far in PCNs and practices – and what they expect in the future

Dr Dan Bunstone, clinical director, Warrington Innovation Network PCN, Cheshire

Dr Neil Paul, clinical director, SMASH PCN, South Cheshire

Luisa Garlick, digital transformation lead, Northwich PCN and PCN manager SMASH PCN, South Cheshire

Dr Matthew Prendergast, clinical director, Southampton North PCN, Hampshire

Michael Penston, digital transformation lead, Southampton North PCN, Hampshire

Daniel Gollop, digital transformation lead, Wandsworth PCN, London

Overview

Victoria Vaughan: The implementation of digital and transformation roles in PCNs has had little in the way of guidance, which will have led to inevitable variation. So how have you each implemented the roles in your PCN?

Dr Neil Paul The variance in people and backgrounds, while an opportunity, has caused some issues. One of the problems is: what is the role of digital and transformation lead (DTL)? Is it digital? Is it transformation? Is it transformation of digital? Is it a bit of both? We’ve gone with two people sharing the role, each with slightly different skill sets – one who is, dare I say it, more geeky and the other with the role of project manager and helping to support practices.

Dr Matthew Prendergast We have Michael, who is a computer science student in his fourth year at Southampton University. He volunteered to work on our vaccine programme and now is helping in an IT management role. We have a very IT-literate population, but we weren’t really exploiting that. About five years ago, we were quite worried about Babylon and GP at Hand because they were looking to expand. We felt that for our target audience – the students that come to our university – it would be a very compelling offer for them to see a sign on a board and sign up electronically.

We needed to have an online offer – which paid real dividends during the pandemic – so we purchased it. Then we started marketing. Our population has gone up from 15,000 to 29,000 in three and a half years, which is pretty good. And that’s been because of ease of access. Those patients were there, we just didn’t tap into them and now we do.

And then Michael, who’s an excellent coder, decided he’d write one himself, which is much better and integrates everything. He’s developed software for registration online and an online booking system. It’s helped even with simple things, such as rationalising the appointments so we can search for them properly.

Being able to sit with reception next door and actually see what the challenges are means you can target those more effectively and utilise whatever skills and time you have in a more efficient way.

Michael Penston

Michael Penston There’s not been much guidance for managers or integrated care boards (ICBs) on how this has to be carried out, and that can be quite useful in providing a bit of freedom. I think it’s useful to have a person with a technical background on the ground in primary care. A lot of the people who are very technically minded are in NHS Digital and then they don’t often see how things work day to day in a practice. Being able to sit with reception next door and actually see what the challenges are means you can target those more effectively and utilise whatever skills and time you have in a more efficient way.

Dr Dan Bunstone Similar to Neil, we have a couple of people doing the role to bring in different skill sets. So we have somebody whose focus is around aligning all the digital offerings in all of their guises. I’ve got a particular bugbear with digital because that includes everything from asynchronous email through to video consultations through to AI triage. We’re creating hubs in the PCN so that practices can maintain sovereignty but also work from a hub and a communal resource. It’s almost like a super-practice. The practices work independently, no question about that, but you get the benefits of back office shared function, shared triage, and shared services. We’ve set up a System One hub and we’re aligning appointments and all the processes behind it. Every time I say ‘hub’, you’ve got to imagine it’s like saying car – there’s so much back end to all of it. We’ve got PCN-wide triage and a proactive hypertension service and we’ve created a pharmacy hub, too.

Daniel Gollop I’m about a month into the role now, and what’s helped me is linking in with the ICB and finding out what funding options are available. And then, I can take that back to the managers and clinical director just to compare the different options and make suggestions as to what’s best to go with.

Victoria: For those who are quite far advanced in all this, what advice would you have about how to start maximising the role?

Matthew The first thing is to do a stocktake to see where people are because you’ve got to bring people with you, and to do that, you need to find their level. For some GPs, the idea of everyone going online is awful – they say it will exclude lots of people. But we found that doing it online as a first option works because we’ve allowed an environment that means people find it easy. It’s not exclusionary. They find it easy to go online to book. And as a result, we don’t have long waits on the phone. So, for those elderly patients who can’t book online, they ring in and they get through in two minutes.

I consistently get people saying that they couldn’t do that; it just wouldn’t work in their practice. And I really do challenge that because I think it can work. What you’re doing is allowing space for everybody.

Neil Purpose is very important. Practice managers have different skill sets – some are IT literate, some aren’t – but all of them are very busy people with little headroom. As this role is essentially funded through ARRS, practices could be saying, ‘I could be spending that on a MSK practitioner or a physician’s associate or another clinician to actually see patients. So, what is it that this role is giving?’ So, you need to have purpose and get buy-in to that purpose.

Luisa Garlick Automation is something that is creeping in – health tech is a big thing for general practice. Our DTLs in SMASH PCN are able to work with practice managers on a one-to-one basis to support them through changes. The role gives us the ability to have that additional support for practices. As Neil says, practice managers are incredibly busy and it’s very reactive. With DTLs, we get the opportunity to be more proactive and support practices.

Impact

Victoria: When you were thinking about your digital and transformation leads, what was your priority? What were the problems that you hoped they would fix?

Dan From a strategy and theory perspective, it’s all the things that we can potentially do to improve care and access, getting the headspace and time to achieve that. There was a paucity of opportunity for that to happen. So for me broadly, it was around how we could start addressing a need in a way that’s really effective. There are lots of promises in digital, but not always a lot of delivery.

Matthew I get hundreds of emails every day from various providers saying, ‘I can do this, that and the other’. I have no idea whether they can or they can’t and I could spend a lot of money and achieve nothing. I forward them to Michael and he cuts through the crap and says: ‘Well, this is good and this isn’t’.

I think the frustration for some colleagues is that they’re too busy or were born in the wrong era and just don’t understand it.  And that’s what this role is great for because it allows someone who doesn’t have a clue – and why should they when they’re a doctor? – to develop and give patient benefits by moving into the 21st century.

I think the frustration for some colleagues is that they’re too busy or were born in the wrong era and just don’t understand it

Dr Matthew Prendergast

Michael A lot of it is implementation. I mean, there are certain solutions – really good solutions, some of them – that have been procured, but they’re not being implemented. I’ll give an example. Apex, the reporting tool for appointments, is a really useful tool, but practically no one in primary care actually makes good use of it. And they must pay a fortune for it. So the role is actually bringing that data and showing people how to use it and how it can improve their planning. You know, it can improve how they plan sessions and other services that the surgery offers. It’s a nice little bridge between all these services.

Luisa It’s measuring impact as well, isn’t it? I have a team of paramedics and occupational therapy (OT) social prescribers, and I’m actually able to use small amounts of data to show what their impact is. For example, we’ve got cognitive clinics that are run by our OTs and we can actually start to put some data together and present that. It’s trying to evidence the impact of the ARRS roles as a shared team.

What you say about there being so many companies with so many different solutions trying to access GPs and clinical directors resonates with me. It’s almost like there’s this digital data fatigue that could overwhelm practices. And so the DTL role is very much there to kind of sift through and look at what will work and what might not work and put those solutions in front of the right people.

Neil Although the DTLs work for the PCN, we always say the PCN is the practices and the practices are the PCN. So, hopefully, the practices feel that the DTLs have been useful for them. Some of that is just being able to ring them up or emailing to ask a query. It might be a very simple thing like asking why EMIS isn’t finding these codes? Or it could be: ‘I need a new phone system tomorrow’. So, you know, it’s an added resource.

We’ve got lots of projects – remote gynaecology services and some minor surgery – and I think the DTLs have helped us deliver those projects. But they’ve also acted as the glue between the practices.  They’re helping to bring people together but also allowing the headspace to write stuff up and reflect. Often in primary care, you’re just running on a treadmill constantly. And you need a few people who aren’t answering the phone, dealing with complaints, and dealing with staff issues.

Challenges

Victoria: One of the things you mentioned is that not all GPs are on board with this. Is there a culture change needed among GP partners and GP practices so that the potential of digital transformation is embraced?

Matthew Change is really difficult in GP practices, which have very established ways of doing things. Part of the problem with a lot of practices is that change takes effort, and when people are really busy, they find that really, really difficult.

You’ve got to get the support of the management to put things through because the first thing reception often says is, ‘This is rubbish, this doesn’t work’, and you’ve got to be willing to say, ‘Well, we need to refine this. It’s not going to work the first time – nothing survives first contact, as they say’.

The elephant in the room, of course, is being on different systems. In our PCN, half the practices run on System One and half on EMIS. That makes life very difficult.  I do think forward-thinking PCNs are on the same system, but the problem is trying to persuade those practices who aren’t on it to change. That’s really, really difficult.

Michael There are a lot of people in the practices – GP practice staff and ARRS staff – who are really keen to do some forward-thinking positive health interventions ahead of time, but can’t really access that data very easily. I mean, you’ve got search modules in all the clinical systems – you’ve got Apex on demand and all these external things – but actually just being able to use them to find the right data is quite challenging for a lot of people. I think we’ve been able to help quite a lot in that respect.

Luisa I totally agree. In the past, we’ve had lots of different data sources, but it’s not been the most up-to-date data, so it’s not felt very real for your area. At the minute in Cheshire, we are working more closely in community partnerships, and that is very much looking at the data and how it links to health inequalities, DES and making sure that we’re keeping a refreshed approach to what is happening in our communities. SMASH is quite interesting because the PCN is actually over three towns. We’ve got a different way of being able to assess different levels for each town, which keeps us busy. So it’s really using the tools that we’ve got.

I think the access module has been really good for us in terms of digital access and looking at digital inclusivity. Arden’s manager, for example, gives us all that kind of rich access data.

NHS dashboards are a little bit clunkier, but if you’ve got somebody like a DTL who can interpret that and provide that information for practices then it’s just like Michael says, it’s pulling in that information and having the time to interpret it and distribute it.

I would hate a DTL person to spend their entire life just being a business intelligence person. There are data geeks who can get you the data.

Dr Neil Paul

Neil I would hate a DTL person to spend their entire life just being a business intelligence person. There are data geeks who can get you the data. It’s more about how you apply that information to what the practices are actually doing. We’ve probably all sat in meetings where somebody’s presented a spreadsheet or a graph and they’ve not really been able to explain what it’s for, or what it means or how you should change something. I think one of the things that the DTLs can bring is that halfway house between the data and actually understanding how practices run, how they operate, and how you can change things. Because the role is at a PCN level, and because the clinical director is usually one of the partners in one of the practices, it’s not seen as them; it’s seen as us. And that is a fundamental change.

I was just reflecting on what Michael said. I have a good working relationship with our local commissioning support unit (CSU), and they have procured certain things and there’s a training academy, but they’ve never really come in to help my business deliver more. They’ll often say that the rules say you’ve got to do this, but they’ve never really come in to actually support us. I think the DTLs have got it right – they’re seen as being on the practice’s side.

It goes back to the PCN having agreed a purpose and what it wants to achieve. And it has chosen somebody to help implement that, so why would there be hostilities? You’re only going to get hostilities if you’re trying to implement or impose something that people don’t want to do. Okay, so there’s always change resistance. Their roles may vary, but DTLs have got to understand change management and project management implementation. That’s perhaps why a few of us have gone down the route of having more than one person, although some people will have both of those skills.

Having somebody on your side who can help you out is, actually, a very positive thing. And I think, on the whole, most people who’ve got DTLs like them. I’ve not come across much hostility.

FUTURE

Victoria: What is the potential of this role in PCNs and practices?

Neil You know, seven practices might be recording their appointments in about 14 different ways so standardisation and harmonisation is perhaps a key thing. Even if you don’t want to become one super practice, there are advantages to standardising the data and coding things the same way. Having somebody supportive on your side, who’s got good relationships with the practice staff, to help with some of that, is vitally important.

We’ve just seen a fairly derisory uplift suggestion and we’re constantly having to get more and more productive. And DTLs are very good at understanding processes, trying to understand the waste in the system and actually root it out.

Daniel Gollop I think it’s just facilitating that chain from a change management perspective. So some practices have been a bit more receptive to the changes than others. For instance, I logged in to do some audit searches at one practice and they were saying, ‘Oh, who’s this logging into our system?’ I think it’s important to get in early, introduce yourself, build those relationships and form a level of trust.

Michael I completely agree with that. When you’re trying to make changes in a practice, you’re basically going into someone’s house and saying, ‘Right, we’re gonna rip this up and change this and do that’. And you can’t really do that, you know? It’s a very delicate process of being on board with the management teams.

I’m very lucky here – Matt and the partners have integrated me into the management meetings and it’s much easier to work that way. Otherwise, it’s very tricky just to walk in and say we’re going change this and throw it up in the air. In terms of the future, I’ve seen the immunisation strategies, which look really digitally positive. I think over the next few years, it’ll be implementing some of those strategies from NHS England. There are a lot of good, well-thought-out ones out there – it’s just having an inside person in the PCN to actually understand and synthesise that guidance. That’s where I see the DTL role going. 

Victoria: Let’s fast forward 10 years to a time when DTL roles are well established. What do you think your practice will look like digitally?

Matthew The website will be the key to the front door and that’ll have a range of offers on it, which you can book digitally. You can book a pharmacist, order medication, go on AI triage, send in things – the offer is going to be much greater. AI is going to be a huge issue, both for our jobs and for the future of healthcare. I don’t think anyone knows what that’s going to look like in five years, let alone 10 years. A few practices will embrace this completely, and they will tend to be the bigger ones because, by nature, this is time-saving. The problem is how are you going to bring the small practices along? And I don’t know the answer.

I think that’s a real frustration for the Department of Health. I don’t agree with their frustrations in many instances, but I do think it’s really hard. PCNs are a transient thing because we’re going to aggregate into a large practice PCN very soon – because it makes massive sense to do that. I think the traditional general practice is going to be far rarer in 10 years’ time than it is today because you can’t embrace all this technology as a standalone single-hander; there’s just no way.

AI is going to be a huge issue, both for our jobs and for the future of healthcare. I don’t think anyone knows what that’s going to look like in five years, let alone 10 years

Dr Matthew Prendergast

Neil Ten years is almost too hard. Ten years ago, could I guess where we are today? Wearable technology, data logging, and AI interpretation? It’s going to be more than the Apple watch reading your ECG and your blood oxygen. You’re going to be constantly monitored. And if that moves to health promotion, then I think that’s brilliant. What we know is that digital is going to be a huge part of the future of healthcare, and there needs to be a human element. Wherever we get to will need people with the right skills, knowledge and expertise to support the clinicians. I could probably double or triple my DTL iNeilut and still have more work for them to do.

Dan We’ll get to a place where patients get the right care at the right time. There will be good front-end triage, people aren’t lost and there’s no duplication of appointments. There are fully utilised ARRS staff, but, actually, there’s probably much less need for staff because you’ll have AI augmenting health care and democratising data. What I mean by that is enabling people who don’t necessarily have a trained skill set. If you’ve got a Garmin watch, you know everything about yourself, but you don’t do anything with the data. So AI will support you to manage the data. And there will be more automatic population health management that doesn’t rely on coming to see me or my practice nurse but gives you advice via a different route.

Daniel The future of the role will be helping to integrate systems further – improving standardisation so there is less fragmentation across services.

Luisa For me, it’d be very much more collaboration and being able to respond and react to the needs of your local population whilst obviously working alongside digital as a solution, like Dan says. It’s being able to react more fluidly with the information that we’ve got.

Michael I think the interoperability in primary care and across the NHS is really the main issue we face right now. There are so many different moving parts in the NHS, and none of them talk to each other at the moment. Clinical systems and wearable technology need interoperability – that’s really where it needs to go in the next 10 years and where funding needs to go. That’s how it will run smoothly and efficiently in the future.