Controversy in PCN world: musings of a clinical director

The introduction of primary care networks (PCNs) in 2019 was met with lots of fanfare and promise. There was a buzz of excitement in primary care about whether this could deliver a way forward for increasing pressures and dwindling morale. So, every practice signed up.

Fast forward to December 2019 and the draft PCN DES (direct enhanced service) for 2020/21 was published. Shock! Horror! It contained a myriad of specifications that seemed too much too soon and rightly there was a collective snort and kicking of the proverbial ball across the fence. The centre seemed to listen and following further discussions with the British Medical Association’s General Practitioners Committee (GPC), they proposed a revised PCN DES specification. All seemed okay… or was it? 

Cue a series of calculations and debates, and in some quarters, we were told the DES was not to be believed. Other quarters argued that it offered hope for the future. Decisions, decisions. Where do we go from here? 

I decided to reflect back to the origins of PCNs and clarify my reasoning for continuing down this road. 

Start with why

Simon Sinek, in his book Start With Why, describes something called The Golden Circle, a philosophy of what drives human decisions and behaviour. The Golden Circle starts with understanding the why – what is the purpose for a thing? – before exploring the how (process) and then the what (the form or object).

While reflecting on my first year as a PCN clinical director (CD), I decided to play around with this construct and use it to explore PCNs and my role as a CD.

So, the why. 

There is a fantastic little movie titled Room in which a young lady is abducted at the age of 19 and kept for seven years in a small room with only basic essentials. While in captivity, she gives birth to a child, and for five years the little boy’s whole world consisted of this 20 square foot space called ‘room’. It was all he knew. 

That was me a few years ago. All I knew was how to be a GP. My practice was my world.

I went straight from GP training into partnership, which at the time was considered a real coup. But it did not take long to realise that despite my best efforts, I was struggling to meet the needs of a large proportion of my patients – at least in a way that felt fulfilling. 

Workload was increasing, patient demand never-ending, and patient and staff dissatisfaction escalating. It felt increasingly like the proverbial hamster wheel – lots of movement but not really going very far. Then my managing partner at the time, Caroline, introduced me to the clever people at the National Association of Primary Care (NAPC) who had started a movement called The Primary Care Home. The principle was simple – you start with the GP and the registered list and enhance the offer with a range of additional primary care and support staff to care for that patient list. 

For me, that was a light-bulb moment. My public health degree had taught me about social determinants of health, but my practice as a GP had been very focused on the reactive medical model of care. It became obvious that to better meet the needs of the population I served, I had to move beyond the traditional model of general practice. The fact that the joy of work and fulfilment in practice increased was just an added bonus. 

This was the ‘Holy grail’ of integrating health and social care models, but at practice level – close enough to the patient to make real impact. It turns out lots of other clinicians felt the same, many of whom are on my NHS Confederation PCN Network group. A very inspiring bunch.

By the time I caught on to Primary Care Home, there were already over 200 sites across the country and the movement was growing. The wider NHS could see the potential in this way of working and wanted rapid implementation and access to all GP practices in England, leading to the birth of the original PCN DES.

The rest they say, is history. 

The why is simple. To make a step change in primary care service delivery and to better meet the needs of our practice populations, we need to involve a wider range of primary care support structures that are not available to us within our individual practices. With the added side effect of improving the satisfaction for patients and the fulfilment for the staff involved.

Then how

According to Simon Sinek, the how includes all the processes that evolve directly from the why. To provide this array of enhanced primary care services or support, you need resources. Plain and simple.

I had always thought the greatest resource we needed in primary care was money – after all, there always seems to never be enough of it and we in primary care always seem to be underpaid compared to other parts of the system. While a greater share of the NHS cake is definitely needed and welcomed, the greatest resource we have in the NHS is people. 

This has been glaring to me in the three years we have been a primary care home/network. For the first two years, we had absolutely no external funding, yet with the right people round the table, we were able to commission separate projects with our local gym, voluntary sector and fire service, among others. It was all done on a shoestring and lots of goodwill, but the enhanced primary care services were born nonetheless. 

But we also need money too. Otherwise, a disproportionate amount of time and energy is spent on sorting the funding and sustainability of services. The PCN DES provides these two elements to primary care, which is unprecedented. 

We have access to a range of staff that can be employed at PCN level and we have the necessary funding for the staff. Invariably, with this much funding coming from the NHS, there is the bound to be accountability. This is perfectly understandable: after all this is public money that is being made available to us. The onus is on us as PCNs and primary care leaders to be good stewards of the public purse and reward the trust placed in us by the centre.

The fact that some GP practices and PCNs are struggling to rationalise the PCN DES, stating that funding may not cover the costs of delivery, is interesting. I think this comes down to two things: 

1) Motivation: if the motivation of practices is purely on funding and money, then delivering the DES will look a tall order and it will not quite fit and may look too difficult. If, however, the motivation is to improve patient care, to do things differently and improve work fulfilment, then the DES looks like a great opportunity and is very do-able. 

2) Comparing this DES to previous iteration is flawed: it’s like comparing the frozen pizza from the supermarket to a freshly made, artisan pizza and thinking they are both pizzas and should taste the same. They don’t! Previous DES’ have been transactional – a specification tells you your targets, tells you how to deliver, when to deliver and then how much you get paid. Simple and straightforward. This new PCN DES is transformational – it tells you what to deliver and the timeframe, but with flexibility around how and who. And by the way, we’ll give you some staff that could help you with the work and also pay 100 per cent of their salary.

If we see the greatest resource as people, as alluded to earlier, then the tasks outlined in the DES look a lot more achievable than perhaps previously thought.

So what?

I have touched on this briefly earlier, but to give all practices nationally a chance to join the movement and the new opportunities, there had to be a mechanism. It couldn’t come through the general medical services (GMS) contract as that would be a significant change and would take too long to negotiate. The available method for delivery was therefore a DES. Similar to other DES’, but with a difference.  

I will admit, it’s not perfect. (Thought I’d throw that in there, as I’m sure many of you are starting to think that I must be suffering from some delusional disease that I picked up after drinking NHS Kool-aid).

It still feels top-down. This is understandable to some extent due to the amount of public money being invested, but nonetheless uncomfortable. We are definitely more creative and innovative when we have less restrictions from the top. But there does seem to be a shift in the tide and a hope that the centre is listening more to the voice of primary care. 

The draft 2020/21 PCN DES was released for consultation and was then reworked based on feedback from primary care. This is a first and is a credit to Dr Nikki Kanani and her team at NHS England and NHS Improvement and we hope it is a sign of even better things to come. 

There are challenges with recruitment to the different roles. Not every PCN has been able to recruit in the last year. My PCN still doesn’t have a PCN pharmacist one year down the line, though we are out to advert and have interviews lined up. But we have an excellent social prescribing link worker, a very enthusiastic community nurse doing care coordination and have recruited to our first contact physiotherapist with great feedback in just the first few weeks. 

Point is, get the staff you can and work from there. Help them focus on the areas that are priority for the PCN and work with your local clinical commissioning group, federation or community trust about how they can help you with some of the other roles. 

There are concerns about the threat to traditional general practice and the independent contractor model. As a GP partner, while I am concerned about this, I see this as a job for the BMA and GPC to handle. They have the expertise and the knowledge in this area and that’s what I pay my dues for. They should oversee this area and mitigate those risks on my behalf.

To conclude

What a ride! Excitement, anticipation, disappointment, elation – a cacophony of emotions, all in the last year.

I have not even mentioned all the progress that we have been able to make as PCNs during the COVID-19 outbreak that have brought practices and PCNS even closer together and working more collaboratively within the health and care system. 

I believe this is a time unlike any other for primary care to mature. To be not just clinicians, but part of a whole system solution to the health of our populations. The system is listening, the NHS is listening, the government is listening – can we harness a clear and articulate primary care voice and help shape the future of primary care delivery for generations to come? The best is yet to come!

Dr Tayo Kufeji is a GP, clinical director for The Bridge Primary Care Network and member of the PCN Network’s clinical directors board. Follow him on Twitter @tayokufeji

You can access a range of resources on the DES produced by our PCN Network:

• Watch the recording of a webinar which explored the main issues and considerations.
• Download a set of Q&As.
• Download a short briefing on the benefits and challenges.
• Take a look at our quick visual summary: