How Gloucestershire ICB works with PCNs

Gloucestershire ICB has 15 PCNs, including Central Cheltenham PCN, which was awarded 2023 PCN of the Year. Here, Gloucestershire ICB CEO Mary Hutton shares the ICB plans that most affect primary care and PCNs.  

Victoria Vaughan (VV): What is the situation for primary care in your area at the moment?

Mary Hutton (MH): We were working together for quite a period of time prior to the formal ICB setup. We’ve got six integrated locality partnerships, 15 PCNs, 64 GP practices and 67 dental practices.

Appointments in primary care are up about 26.2% from 2019. That’s a huge amount of extra capacity, which obviously isn’t fully funded in the system.

We have had good recruitment of GPs in Gloucestershire. Compared to 2019, we are pretty flat for GP numbers. We’ve seen an increase in additional roles and an increase of about 8.5% in nurses in primary care and we’ve got a very big social prescribing provision.

So, there is an increased capacity in primary care in Gloucestershire, but we did not expect to be dealing with this level of additional demand, so that is a problem.

We’re now trying to understand where that demand is coming from so that we can support primary care by redirecting some of it to alternatives, such as pharmacists. And we’re about to launch a campaign about the benefits of working in Gloucestershire. The last time we did that, it seemed to work well particularly around attracting primary care staff into Gloucestershire.

Over the next year, we hope to resolve some of the issues to make primary care more comfortable for our practitioners.

VV: What’s the relationship like between Gloucestershire ICB and primary care? And how is the ICB supporting primary care?

MH: We are very fortunate that our primary care is really strong in Gloucestershire. We have good support when we introduce new initiatives like fit testing and primary care guidance. They really work with us.

So, in return, we’re trying to support primary care. We’ve had quite a lot of new premises developments over the last number of years, which have been positively received by primary care.

We have invested in a team who work with primary care. As well as contracts, they work on primary care, locality, and place development.

We are aware, though, that primary care is facing significant financial challenges. And part of it’s the challenge around capacity. We’ve seen an increase in on-the-day appointments, and therefore we’ve seen some length of time wait for routine appointments. And obviously, doing 26.2% more is quite a significant challenge.

VV: Balancing same-day care and continuity of care is tricky. Continuity of care has been proven to have better outcomes in the long run but it’s often pushed out by urgent on-the-day care. North West London ICB was looking at setting up same-day access hubs, which has been quite controversial. Is that something Gloucestershire ICB is looking at?

MH: In Gloucestershire, we’re more in the camp of continuity of care. You might have seen the recent study by the University of Cambridge and INSEAD Business School, which showed that continuity of care reduced costs massively. We need to be careful that the model fits the needs of our population. We have a mixture of rural and urban populations and I don’t see how that [same-day access hub] model works in a rural population.

Since 2019, we’ve seen a much-reduced demand for secondary care and urgent care, so we’re certainly not going to jump into a new way of working until we’ve got a tried and tested model for it.

Obviously, we’d have to understand how primary care manages increased capacity next year if their funding isn’t sufficient to meet it. But at this stage, our primary care is really responsive.

Our primary care really took on board the Productive General Practice work that was available to them a number of years ago. And we do quality improvement projects at PCNs, which is how one of our PCNs won PCN of the year. That opportunity to really understand the needs of your population and to tackle some of them brings energy into primary care because it gives them the ability to tackle some of the difficult issues.

So, our practices are very engaged in quality improvement projects and really want to extend it.

VV: Do you have Fuller integrated neighbourhood teams in Gloucestershire yet and how are PCNs involved?  

MH: In terms of integrated neighbourhood teams, we have them in our community trust and, obviously, they work closely with practices already.

In two areas – Cheltenham and Rosebank in central Gloucester – we’re piloting what truly integrated teams look like across healthcare, social care and the community trust. We have a joint director for the ICB and the community trust to help us understand how we wrap general practice and community services together around a population.

In Cheltenham, for example, we are using frailty as one of the themes and working through how it could be better.

We are focused on understanding the inequalities in our area. In Gloucestershire, we have a good life expectancy – 80 years for male and 84 for females – and an average of 67 years in good health. But there’s an 11-year difference in healthy life between our wealthier and least wealthy areas so we’re trying to think about how we address that huge disparity as we work through those projects at a PCN level.

And we have a PCN group in our localities. There are six localities, which work around the district – we’ve got a two-tier system – with the voluntary sector. Together, they’re taking forward some of those projects on the wider determinants of health. So, we’re seeing a significant change in how we work across our system.

VV: Are you changing other ways of working that impact primary care?

MH: Yes. We have clinical programmes in Gloucestershire – one for cardiovascular, orthopaedics, cancer, etc. – with patients, consultants, community staff, and primary care. They’re agreeing pathways and talking about what should be moved upstream and what the voluntary sector can do.

For example, in pain management, we found real success in reaching out to the voluntary sector and setting up some alternatives for children and adults in their local areas. This has helped pain management, reduced prescribing significantly and given people a better quality of life.

The other thing we’re working on with our health and wellbeing partnership is exemplar themes to try and bring everybody moving in the same direction.

So, this year, we picked employment, smoking and blood pressure monitoring. People in the voluntary sector are working with people at the lower end of blood pressure. Then also it’s thinking about if people are at crisis point, what alternatives can we provide for them in terms of exercise, classes and advice, etc.?

I’m trying to get a joined-up position in each of our localities so that we know the issue and our response.   

A version of this interview first appeared on our sister publication Healthcare Leader.