Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by primary care correspondent Jack Serle.
Clinicians and managers have been working with haste to launch their primary care networks across the country. They are the key element in the NHS’ overhaul of primary and community care services and will form the base of integrated care systems.
We are now one month into life under the networks, which are alliances of GP partnerships that aim to deliver expanded services through multidisciplinary teams and integrated with other local health service providers.
Staff in the PCNs are developing relationships with their new colleagues within the networks and with other providers.
There has been plenty of guidance on where they need to be and how they can get there. But there has been less guidance on how the PCNs are going to talk to acute trusts. It seems this has been left up to different systems to affect. Though at an early stage, this important component of the integration piece cannot be allowed to languish.
PCNs are working to build bonds between the GP partnerships that make up their core membership. The more advanced will also be building bridges with other PCNs in their “place”, the middle tier of the ICS structure which conforms broadly with their borough or local authority.
They are hiring additional staff and taking on the extended hours component of the network directed enhanced services contract, or DES, which will see them provide extra clinical hours outside their core contract.
And there remains the pressing need to ensure they have robust network agreements. There is a concern that, for some PCNs, the contracts that bind their members together, defining what is required of each constituent part, are a little rough and ready.
There is also a pressing need to build links, or enhance existing bonds, with other local providers. That is, the community and mental health providers, local authorities and voluntary sector organisations. This is an essential component of the PCN model.
A stated goal of PCNs is to dissolve the divide between primary and community services. This integration is pinned down in national service specifications and the network DES as a requirement because it is key to ensuring the primary and community sector succeeds in reducing the burden on the acutes.
Hospital trusts cannot offload activity into the community without robust community services in place to receive the patients.
Some community providers have been left a little bruised by the haste with which PCNs have been formed. There have been murmurs of complaint that there was insufficient consultation with community providers before the NHS declared they are obliged to fit their services around PCN footprints.
However, the NHS has been clear that this union will happen, and quick, despite any disquiet it may cause. And community providers say they are seized of this necessity.
Primary care has gone through a significant period of disruption, but many PCNs are already forging ahead with this work. In some areas, work to integrate the two at a neighbourhood level has been picked up and continues. Elsewhere, community providers may have to wait for their primary care colleagues to answer the needs of their nascent networks.
Building links with acutes
Before long, the same effort will need to go into building links with the acute sector. PCNs are a new entity in the provider landscape and these units of “collaborative provision” are meant to alleviate the burden on the acutes and reduce demand at their front doors.
There is keen interest therefore in what the PCNs can offer the acute trusts. There is also a degree of trepidation.
The acute providers crave consistency from the primary and community services. Consistency in terms of referrals into the trust and consistent services to receive patients discharged from hospital. It will be key to ensuring the PCNs fulfil their demand management function.
The locus for this relationship will be the bridge in the ICS pyramid: the “place”, or integrated care partnership. This is where the providers will speak to each other, as well as the local authority.
There will also be a voice from the commissioner devolved from the ICS-spanning clinical commissioning group. This will be a cut above the integrated, multidisciplinary teams working at the neighbourhood or network level.
Primary care will also need to find a seat at this table too but quite how has yet to be divined. Some areas are incorporating the clinical directors from their PCNs into ICP boards. Others enjoy having GP federations coterminous with their ICP footprints that are speaking for the multiple PCNs.
It is crucial that all the providers are able to build relationships at this point; and that primary care and the acute trusts are able to understand each other’s needs. How that happens is down to the PCNs themselves. There is some debate at present about what is meant by primary care’s “voice” – that is for primary care to define, and it is beholden on them to ensure that it is heard.
The networks were formed at pace and they now must make haste to build the bonds that will unite them and bring in their fellow providers on their local patch. But all the while they cannot neglect their bridges with the acute providers.
- Acute care
- Community services
- Foundation Trust Network (NHS Providers)
- Government/DH policy
- Integrated care
- Local government
- Multidisciplinary care
- NHS England (Commissioning Board)
- NHS Improvement
- NHS long term plan
- Policy and regulation
- Primary care
- Primary care
- Sustainability and transformation plans (STPs)