The Integrator: Crunch time for PCN relationships

We are now beyond the halfway point in the first official “year” of primary care networks, and just how much work is expected of these new creatures is becoming clear.

They are being asked to stabilise the general practice, provide a means to save the GP partnership model, build integrated services, turn “population health” into something meaningful, and lift the burden off the acute sector. Among other things.

We might call these “stretch targets”.

How close PCNs come to achieving them will depend above all on relationships: The strength of the links they develop within (among their members), between (with nearby networks), and without (with other system players).

The advent of the PCNs has brought with it hundreds of new leaders to the fore in primary care. The clinical directors, almost all of whom are GPs, are mostly new to the world of clinical leadership. This has its positives – fresh blood will bring fresh ideas, new perspectives.

But for many areas it also means the others in a health system – crucially, the big existing secondary care providers – have to start again on developing working relationships with a new group of people.

The arrival of these new players – and the substantial financial resource which is on the way to them – has, unsurprisingly, put backs up in some parts, especially with the NHS providers which will be most affected by them.

NHS providers and their representatives recognise the need to play nice with the fledgling new PCNs and their leaders – and even sometimes accept they could be a net positive in the long term – but in reality, relationships are often under strain.

Strengthening them needs to happen fast. There is a dwindling window of time before PCNs hit year two in April, and the more onerous service requirements. From then, PCNs will need to deliver five new service specifications which require close working with community providers, forming multidisciplinary teams with their staff.

Clinical directors are already time-poor. The network contract funds them to take roughly two sessions a week (depending on the size of the PCN) out of their clinical work to dedicate to network work.

They have found their diaries filling up with an ever-expanding number of meeting requests with the wider health system, and need to balance these against the asks from their own network.

Each PCN’s membership will have its own list of priorities, designs on the workforce they have been promised, and services they want to create or redesign.

It is crucial the relationships between PCNs and other providers in their system are strong enough for them to reach shared plans and priorities. Doing so will ensure PCNs are not cuffed into tackling only those priorities that contribute most to waiting lists or emergency care demand at their nearby acute; and that PCNs do not fixate only on GP concerns.

A very important next chapter for PCNs is expanding their workforce.

The NHS community health providers in some areas – which are often mental health, acute or social enterprises, as well as dedicated community trusts – have explored employing the clinical pharmacists for PCNs.

The announcement of the PCN scheme has already had a distorting influence on the job market for these roles. Primary care leaders are seeing this demand inflating wages for these posts. PCNs are reimbursed for their new workforce but only at a flat rate. They can claim a maximum sum for their clinical pharmacists. It is meant to be 70 per cent of the salary but with pay going up that proportion is falling.

There is great nervousness among community providers and ambulance trusts that similar factors will spread as PCNs look to find physiotherapists and paramedics in coming weeks and months.

Losing their staff would exacerbate workforce challenges which are already often extreme.

It will be interesting to see whether NHS England specifies, explicitly or tacitly, that appointing a local NHS provider as employer should become the norm for hiring the next tranche of additional roles.

This would represent a saving for PCNs who would otherwise have to expend their limited time and resources sourcing staff from an already small pool, along with all the admin and complexity of employment, deployment and staff development.

It would underpin the efforts to develop working relationships between PCNs and trusts, and help build some goodwill. It would help PCNs become a supporter of integration – as they have been billed – rather than a disruptor of it; and make a start of closing the historic divide between primary and community services which has been trailed.

But it is also not without risk for PCNs: Contracts and memorandums of understanding would need to be robust to make sure all parties are clear on what they can expect to get out of such a deal. Otherwise, we could see this primary/community barrier closed, only for new divides and disputes to flare up instead.