Dr Claire Fuller: Are PCNs proving to be a success?

Dr Claire Fuller, chief executive at Surrey Heartlands Integrated Care System and author of Next Steps For Integrating Primary Care, shares her insights on PCNs with Pulse reporter Caitlin Tilley

Do you think PCNs are proving to be a success? 
In some places they are and some they aren’t. At their best, they’re incredible. And at their best, people are already delivering the integrated neighbourhood teams, as outlined in my report Next Steps For Integrating Primary Care: Fuller Stocktake Report. There is nothing in this that I think is new. What we’ve done is describe multiple places around the country where it is happening. Many places are delivering a lot of this stuff already. 

Where it hasn’t worked, it will be for particular reasons. It’s the whole inverse care law – the areas that are most deprived have the fewest people working, and we need to do something different. 

The thing that’s powerful about the letter accompanying the report from the integrated care system (ICS) chiefs is the understanding about the development of practices and PCNs, and the evolution into neighbourhood teams. It’s our job to help that happen. 

What challenges do PCNs face? 
When you’ve got multiple practices that are doing one session here, one session there, it isn’t a great way for people to work, because they don’t get the sense of neighbourhood or team. With any change programme, the biggest threat is that everyone is exhausted and overwhelmed. The idea of trying to do something different, even though it will improve the way we work and deliver care, is really hard. So it’s up to us as ICS chief executives to give people protected time and space and the right expertise to do that. 

I think in the past, we expected people to do this kind of thing in the evenings, and [say] why have you not done it? Nobody can work like that. The places that have been successful have had the support and the time to make changes. It is absolutely incredible the things that have been delivered and the improvements to communities. 

Do PCNs destabilise general practice? 
I think it’s the opposite. I’ve seen, increasingly, practices are merging across PCN footprints. But I think what we’re describing is an evolution from PCNs into neighbourhood teams. You need more people than just a few of the additional roles reimbursement scheme (ARRS) hires to do all the work that we need, which is why it’s important that we bring in other partners in the voluntary sector, the primary care and secondary care sectors and the community to create those bigger teams. 

I think if stuff is working, [we shouldn’t] mess with it. Where we’ve got great leadership, leave it alone. Let people get on and deliver. But there are lots of places around the country where things are not working. That’s where ICSs need to come in and help rather than just watching.

Is the ARRS proving to be a success? 
That’s really interesting. When I started this process, all the chief execs said, ‘The ARRS roles, they’re terrible, they’re so inflexible’. But when you get the numbers, there are now thousands of new people working in general practice. [At our meetings we found] there is more flexibility then we thought there was. We’ve had a bit of regional variation in the way forms are filled in, but there is greater flexibility. Why would we think it was a bad idea to have extra people working? Perhaps we’re not using and supporting them in the right way, but I think it’s incredible having that many more people now working in general practice. 

What support do you think PCN clinical directors (CDs) need and how much protected time should they have for leading PCNs?
More than they’ve got at the moment. In Surrey, we increased the [protected] time and I’m fortunate to have the fabulous Dr Pramit Patel. He sits on my executive team and has the primary care leader role, and has extra time from me to bring together all the PCN CDs. He runs a primary care transformation board and does a lot of development work with the CDs. This is why the letter signed by all 42 ICS leaders is so powerful, because it’s a commitment to primary care leaders: that we need to give them more time. We need to help them do this, give them the right skills and the right protection. That may come from the ICS, it may come from other organisations, but there’s a real understanding that we can’t ask people to upend their model on very limited time when they are already exhausted.

I think there are some capabilities that we don’t have in general practice routinely. All other NHS organisations do demand capacity planning, so they can tell you how many people they’ve got working, what work they are expecting, and how many people they need to do that. We don’t even know what we do, do we? We don’t properly record our demand, and not everywhere knows who is working. We need to get better about demand capacity planning, so we can create a baseline of the activity we’re doing. Then when things get worse, we can add capacity. It’s the e-rostering that hospitals take for granted. We should be working with them: and they want to help do that. If somebody can only come in 10am to 2pm, term-time, Tuesday to Thursday, let’s have them in. But at the moment, a lot of places aren’t able to have that flexibility.

What do you think should happen when the current planned funding comes to an end? Should it continue past 31 March 2024?
Because the report is a stocktake, I didn’t ask [those we interviewed]. One thing we did talk about, though, was bundling funding together, and a commitment to work towards that. Instead of being so rigid, it would be for local systems [to say] we’ve got this amount of money, what is the best way to spend it locally? 

That, to me, would have a massive impact.