System overload: PCN digital and transformation update

Digital and transformation leads were added to additional roles reimbursement scheme last October and the deadline for patients to have access to their records has now past. So how are PCNs managing the digital transformation of practices? Emma Wilkinson report for the winter issue

It is just over a year since the role of digital and transformation (D&T) lead was added to the list of additional roles reimbursement scheme (ARRS) positions that PCNs could get funding for. While many are still learning what it entails and building relationships with practices, the introduction of the capacity and access payment (CAP) provided a certain amount of focus and, of course, funding.

Now tasked with developing and delivering on capacity and access improvement plans to unlock the final 30% – worth £73.8 million – D&T leads are working to improve patient experience of contacting practices, making it easier for them to access primary care and also managing demand and ensuring appointments are recorded accurately.

Yet there is much variation in experience, approach, focus and relationship with integrated care boards (ICBs). Some have been left to fend for themselves while others report close collaboration with regional teams. One common theme appears to be a desire to make better use of systems already in place rather than leap to the next new shiny IT toy. 

Getting started
Conor Price, chief information officer for Herefordshire General Practice and managing director of data specialist company Primary Care Analytics, says the D&T lead role was desperately needed and was always missing in primary care, compared with secondary care.

But he notes it was introduced without clear guidance and says there is confusion over the digital ‘and’ transformation aspects. In the absence of any real direction, a job description was produced by Tara Humphrey, CEO and founder of THC Primary Care, which provides support and training to PCNs, which lots of people have adopted because there wasn’t anything else, he adds. In the early days people didn’t know what their remit was and there was a lack of leadership.

‘Now there’s a real focus on digital. NHS England is driving it and the capacity and access plan is trying to push PCNs to think of more efficient and effective ways of managing workload, giving patients access to the practice in multiple ways. It is a really necessary role but there isn’t enough support and that’s the struggle,’ he says.

It’s still very early days, he adds, not least because many of those starting as D&T leads are coming from outside general practice and have to gain the trust of their PCN and practices, he adds. ‘It is difficult starting from scratch and I’ve seen a lot of people come from outside general practice, which is great but it is an incredibly nuanced system and takes time to learn. [They have to] build relationships and understand key areas to focus on.’

Yet there is a lot to be positive about so far, he says. ‘I have been impressed by how well these [D&T leads] have cracked on, getting an understanding of what is being used in the PCNs, looking at the gaps and exploring which tools and systems can close those gaps.’

There has been a realisation that we need to get the basics right first and understand where gaps and issues might be, he explains.

But David Thorne, transformation director at Well Up North PCN in Northumberland, believes the introduction of D&T leads has been a ‘chaotic mess’. It arrived suddenly with generous funding but no
real guidance, he says. ‘In my view only a small minority of PCNs are doing this properly.’ He adds that there is not enough long-term strategic thinking.

Alex Harper is D&T lead at Northern Parishes PCN in West Lancashire. She recently shared her experience of the role at the Best Practice conference and learned that everyone was struggling with what they had been brought in to do. ‘There’s nothing out there nationally that says [what] a D&T lead should be working on.’

She has worked for a decade in primary care, and says the D&T role was welcome news for PCNs who had never been able to access funds for this type of senior leadership position but there was a strong feeling of  worry about ‘what’s coming next, what’s on the horizon.’

Finding focus
The GP contract changes, the CAP and the delivery plan for recovering access to primary care all brought more clarity, Harper adds. ‘For me this is about striking a balance between knowing your stuff and being able to influence the practices into changing things and recognising that they don’t need me to come in as a sort of superhero and tell them how to fix things because they know their patients best.’

Harper sees her job as a support role or facilitator. For her PCN that began with a big baseline exercise to understand where they were starting from, so they could measure the impact of any changes made. She did website audits, secret shopper phone calls, looked at social media and online consultation data.

‘It was very helpful because when I shared that with practices there was an element of competitiveness and it piqued their interest about why a practice was doing a bit better in some areas.’ At the end, she generated a table of key opportunity areas, which fed directly into their capacity and access improvement plan submitted to the ICB. 

One area of focus was increasing friends and family survey responses and standardising questionnaires, which led to one practice getting 190 responses after getting barely any. There’s also been a jump in the number of positive answers. 

The aim is also to increase the number of patients using online services by improving practice websites. 

‘Telephone access is one of my favourite things to talk about because the [practices]were all on cloud-based telephony but were still struggling with the number of calls coming in.’ The work found that for one practice, almost a third of calls were about prescriptions. Other practices that weren’t getting prescription requests had shorter call waiting times, but Harper says it was important not to just switch the service off, because it would damage the patient experience. Instead they have been doing a project to guide patients towards the NHS app and helping them use it. Now prescriptions only make up a quarter of calls to that practice.

At Nottingham City PCN, D&T lead Charlotte Ivers says there is a high proportion of patients who don’t own a smartphone or computer or are digitally excluded for other reasons such not having English as a first language or being unable to read and write. This includes a high population of people who are experiencing homelessness as well as transient populations. 

‘Everything we create in terms of a digital platform, then needs an access route with non-digital means. That has been my focus since I started – improving what I can in terms of digital inclusion and making sure we’re not leaving people out.’

They are making use of Accurx triage. Much of the focus has been staff training and upskilling of reception teams. ‘With the best will in the world we can only have so many reception teams, so many phones and means of access but once patients are coming through, we can triage them to the right place to be dealt with in the fewest number of appointments.’

Digital services company Redmoor Health had already been helping practices implement online consulting systems and when the D&T role came out it seemed a natural progression to support people new to the job. It supports D&T leads and also offers a digital managed service to cover the D&T role.

Dillon Sykes, programme lead for the service, said when the CAP came out it gave the D&T role a focus and funding for initiatives. 

‘For the first two or three months we were pulling all the data and presenting the baseline,’ he explains. Where improvement plans were refused by the ICB they helped to provide more detail and metrics to get them over the line, he adds. 

Getting the data together means that easy wins, such as encouraging more patients to order medicines online, are suddenly obvious to everyone.

David Thorne says his PCN in Northumberland is working through everything systematically and is getting agreement so that all practices are on the same systems and every decision they make is clinically led not technology led. PCNs should not be placing all their focus on looking for the next shiny tech that is going to magically solve their problems, he says, but it’s a supplier-led market at the moment.

‘Suppliers are coming out to immature organisations that have got funding and unclear roles and some kind of expectation and people are procuring systems in a disjointed way. So you have got 10 practices in
a town and they have all got different systems. We’re trying to be much more structured and methodical.’

He sounds a warning note. How does that work if the rumoured procurement framework comes out at the end of the year and you’ve bought a system that’s not in the framework?

The pressure from suppliers can be overwhelming. ‘In a typical day I will have six to 10 approaches from suppliers and if I was a different kind of person I could be easily led.’ It would be too easy to jump at software or apps promising to transform mental health or gynae provision, he adds, because there is a lot of hype.

‘Sometimes the technology you need is very simple. It doesn’t have to be some amazing thing. But when I have been part of clinical conversations there is hardly any clinical conversation, it has all been tech led,’ he notes.

One example is a project called Farm Fit where practices set up a stall, say, at a monthly sheep market. The nurse running it said too much technology would put people off when all you need is a blood pressure check and a chat. ‘I would see that as fulfilling transformation.’

This has all prompted a sudden influx of suppliers on to the market, agrees Price. ‘There is now a problem seeing the wood for the trees, all claiming they can do one thing or another. It is going to be really hard for D&T leads to know what’s good and what’s bad.’ 

Frameworks aren’t necessarily helping the situation and the risk is there will be thousands of practices on different solutions that can create more silos and prevent cross-organisational working, he adds.

Challenges and barriers
One of the biggest frustrations for Price – and he is not alone in this – is that GP appointment data are not fit for purpose. ‘This drives me insane, it really does and it’s caused so many frustrations across the practices.’ The data only record appointments, which are a small part of GP work, and there is no real clarity on true capacity and demand, he adds. This is something that everyone is aware of but it has not been addressed.

For most PCN D&T leads, it has been a steep learning curve in terms of culture and influencing change, understanding products and interoperability, Sykes adds. He says that some of the problems shouldn’t necessarily be laid at their door. ‘If a website isn’t meeting the benchmark, some of that has to be for the supplier to solve.’

‘One of the biggest challenges that D&T leads are facing is engaging with their practices and influencing their practices because there isn’t any headspace or time to sit back. Some practices are saying, do [such-and-such] for us now but actually [the D&T] role is to co-ordinate,’ says Lisa Drake, director of quality, service and improvement at Redmoor.

Another issue is being able to make long-term decisions. And some procurement decisions are being made by ICBs, she says. ‘We’re in a hiatus. Do we stick with what we’ve got, even though we know it’s not great, and focus on making [things] better for the next 12 months? Or do we jump into a different product, a new supplier, a different relationship – and what does that change look and feel like to my practices? Just as importantly, can I influence practices to make that decision?’

A lot of practices will stay with a poor product because that’s easier than managing the change to something that’s just slightly better, she adds. 

Harper notes she often gets called the digital lead and others have said they get known as the IT person. But the transformational part of the job is just as important – and is easily forgotten. At the same time, some practices are more advanced from an operational perspective than they are technically with what is available to them.

‘One of my practices wants to be able to offer patients the ability to change an appointment between telephone and face to face on the NHS app, but there isn’t the functionality so this requires a huge workaround,’ she says.

Louisa Thompson at the neighbouring East Warrington PCN in Cheshire says that when she came into her post, she had big visions. But they are having to get the basics right first. ‘We’re starting small with some changes then getting the team’s confidence that it’s working before working up to the bigger things.’

She says it feels like they don’t have the chance to get something running smoothly before another change is thrown their way. 

Recently they were told about a bid for a pot of digital transformation funding, and they had just three weeks to write plans for it, gather information and get team input.

But in terms of achieving the 30% additional funding based on improvement, PCNs feel secure that they will pass their assessment. ‘It was so wishy washy,’ says Smith. ‘How could they say we haven’t achieved? None of us is sitting back doing nothing.’ 

ICB support
In Warrington, Thompson says they have all submitted their capacity and access improvement plans but there has been no feedback. ‘We’re all sort of proceeding anyway,’ she says, and adds that she assumes the lack of comment to be a good thing. They had the national template to fill in but no other guidance, so they collaborated locally to ensure they were presenting it in a standard way with a standard level of detail.

By contrast in Nottingham, Ivers explains they got their improvement plan back a couple of times asking for more detail about things like timelines. This was tricky but the feedback was helpful. ‘We recently had an email that told us [in detail] what was required [for the 30% funding] so we have been able to [confirm] we have probably achieved this.’

At the national level, Redmoor is in a good position to see the variation in approach, adds Drake. 

‘We saw that some ICBs gathered all the data and supplied them to all of their practices and said that’s your baseline, come back to us if it’s not right. Others gave [practices] a blank spreadsheet and asked them to find their own information.’

‘My personal view is that PCNs need to have a good working relationship with their ICB early to understand what their ICB is looking for as evidence. They don’t want to get into the last quarter of the year and find that the ICB is requiring in-depth data to secure their final 30% of the funding. 

‘If the ICBs aren’t already providing guidance on what they are expecting to see, the PCNs, provider collaboratives and federations should be asking the ICB what they are looking for. The last quarter in general practices is a very busy time. We don’t want people spending hours trying to gather information minutiae at the last minute. They need to understand early what is needed.’

Price notes that ICBs are assessing PCN improvement plans in very different ways. ‘Vague [details] are enough for one ICB and definitely not for another. The guidance document is fair and you can see why it is done that way, but I don’t know why we haven’t seen better guidance.’

What is needed, says Price, is more engagement from national and regional teams because there are areas where there is no support between the ICB and PCNs ‘and that should be frowned upon’.